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Emergency Neurosurgery

What Are Subdural Hematomas?

The human brain and spinal cord are covered by layers of protective membranes called meninges. A hematoma is a collection of blood in an organ or tissue. In subdural hematomas, or subdural hemorrhages, blood or blood products collect between two of these layers: the arachnoidal (superficial) layer and the dura or meningeal layer. They’re common among people with head trauma. They may be acute (start quickly) or chronic (develop slowly). Acute or very large hematomas may cause high pressure inside the skull (intracranial pressure). The result can be compression of and damage to brain tissue. This may be life-threatening.

What Causes Subdural Hematomas?

The usual cause is a shearing injury that tears the vein crossing the subdural space. The tear lets blood into the space. Contusions, other kinds of hemorrhage, and rarely abnormalities of blood vessels such as arteriovenous malformations or aneurysms can cause bleeding. These hematomas are common in elderly and alcoholic people because of brain wasting (atrophy) and frequent falls. Babies can also have them (e.g., shaken baby syndrome). Risk factors are things that make bleeding likely: medicines (e.g., anticoagulants); brain atrophy (e.g., dementia, alcoholism); and falls and trauma (e.g., movement disorders, stroke).

What Are the Signs and Symptoms of Subdural Hematomas?

Symptoms depend on how serious the injury is and the hematoma’s size and location. Symptoms can start right away or weeks or more after injury. Some people seem fine at first (called the lucid interval) after the injury. Pressure on the brain can then cause loss of consciousness or changing levels of consciousness, vomiting, headache, dizziness, disorientation, slurred speech, amnesia, and seizures. Personality changes and abnormal breathing are possible. Blurred vision, abnormal eye movements, and different sized pupils can occur. People can have walking problems and limb weakness on one side of the body. Chronic and subacute hematomas often cause headache, mild weakness, slow thinking, speech abnormalities, mobility problems, and confusion.

How Are Subdural Hematomas Diagnosed?

The preliminary diagnosis is based on a medical history and physical examination. Computed tomography (CT) of the head without contrast will show hematomas.

How Are Subdural Hematomas Treated?

Treatment depends on the examination results, symptoms, hematoma size and location, and whether the hematoma is acute or chronic. Immediate surgery may be done. Other options are observation in an intensive care unit and outpatient treatment. For certain acute subdural hematomas and symptoms (e.g., coma, weakness), surgery is needed to remove the hematoma. People with chronic hematomas in stable condition can be watched until they need treatment.

People who have bleeding disorders or take drugs such as warfarin or aspirin need to treat the bleeding problem.

Recovery may be slow, even up to 2 years. Children generally recover faster than adults.

DOs and DON’Ts in Managing Subdural Hematomas:
  • DO protect yourself and your children. Use seat belts, car seats, and safety sports equipment.
  • DON’T participate in contact and recreational sports until you have permission to.
  • DON’T ignore symptoms. Call your health care provider if symptoms don’t improve or they get worse with treatment. Call if you have new symptoms.
  • DON’T use any medicines (including over-the-counter and herbal products) without first asking your health care provider.

Contact the following source:

  • National Institute of Neurological Disorders and Stroke
    Tel: (800) 787-6537
  • American College of Emergency Physicians
    Tel: (800) 798-1822 or (972) 550-0911
  • American Stroke Association
    Phone: 88478-7653

Copyright © 2016 by Saunders, an imprint of Elsevier, Inc.

Ferri’s Netter Patient Advisor

What Is a Subarachnoid Hemorrhage?

Subarachnoid hemorrhage (SAH) is sudden bleeding into the space that’s between the brain and the middle membrane covering the brain. It’s very dangerous. Up to 10-15% of people die before reaching the hospital. As many as 40% die in the first week. About half die in the first 6 months. Also, more than one-third of survivors have major neurologic problems.

People older than 50 and women have higher risks of SAH. Because finding aneurysms that haven’t burst in people without symptoms is hard, most SAHs cannot be prevented.

What Causes an SAH?

Causes include bleeding from a burst aneurysm or arteriovenous malformation (AVM), congenital conditions, and head injuries. Injuries result from falls in elderly people and motor vehicle crashes in younger people. Smoking, cocaine use, alcohol, using painkillers for a long time, and birth control pills have been related to aneurysmal SAH. High blood pressure (hypertension), blood vessel disorders, multiple aneurysms, fatty liver, cancer, and infections are also linked to these hemorrhages. A strong family history of aneurysms may increase SAH risk.

What Are the Signs and Symptoms of an SAH?

The classic symptom is a sudden, severe headache—the “worst headache ever.” Other symptoms include decreased consciousness, loss of movement or feeling, and mood and personality changes including confusion and irritability. Muscle aches, nausea, vomiting, eye pain, light bothering the eyes, seizures, stiff neck, and vision problems may occur.

How Is an SAH Diagnosed?

The health care provider makes a preliminary diagnosis based on the medical history and physical examination, especially of the nervous system and eyes. Imaging studies and laboratory tests will be immediately done. The first is usually urgent cerebral (head) computed tomography (CT) without contrast. Cerebral angiography, magnetic resonance imaging (MRI), electrocardiography (ECG), and spinal tap may be done if the diagnosis is unclear. People with SAH have blood in their spinal fluid.

Several scales for grading SAHs are available; the most widely used is the Hunt-Hess scale.

How Is an SAH Treated?

Treatment aims to reduce pain, swelling, and severity of cerebral vasospasm; relieve nausea and vomiting; prevent seizures and rebleeding; and save lives. Treatment also tries to relieve symptoms and prevent complications such as permanent brain damage (stroke). A medical team is needed. People are usually in an intensive care unit (ICU) in the hospital. Surgery will fix aneurysms, remove large collections of blood, or relieve pressure on the brain. Strict bed rest is critical. Activities that can increase pressure inside the head (bending over, straining) must be avoided. Drugs include stool softeners or laxatives to prevent straining during bowel movements, blood pressure medicines, pain killers, and drugs for anxiety and seizures. Oxygen and fluids are given.

DOs and DON’Ts in Managing an SAH:
  • DO go to the emergency room or call the emergency number (911) if you have SAH symptoms.
  • DO learn everything you can about your injury. Join a support group if you think that would help.
  • DO continue to have follow-up health care provider examinations. Follow all your doctor’s instructions. You may also need physical, occupational, and speech therapy.
  • DON’T smoke. People who smoke have a worse prognosis.
  • DON’T miss your follow-up health care provider visits.

Contact the following source:

  • American Academy of Family Physicians
    Tel: (800) 274-2237
  • American Stroke Association
    Tel: (888) 478-7653

Copyright © 2016 by Saunders, an imprint of Elsevier, Inc.

Ferri’s Netter Patient Advisor