Congratulations to Dr. Noah Berland, aka Julia Man-Child, for this month’s Save of the Month.
Dr. Berland was in Fast Track getting peppered with Shetty trivia when a middle-aged man came in complaining of headache and pain in his right leg after having what appeared to be minor trauma a week before. He had stood up while cleaning a chimney and hit his head on the ceiling above him. He denied LOC, nausea, vomiting and was not on blood thinners. He reportedly looked great and could easily have been discharged with acetaminophen, but Noah picked up a subtle weakness of his right leg. He immediately ordered a head and c-spine CT, and worked hard to quickly get the patient to the scanner. The CT showed a massive subacute subdural hematoma with 11 mm midline shift. Neurosurgery took the patient to the OR and drained the subdural, and the patient is doing well post-op. Noah baked him cookies and brought them to him in the PACU.
A REVIEW OF SUBDURAL HEMATOMA (SDH)
Image courtesy of Rosens Emergency Medicine, 9th Ed
SDHs can result from minor head trauma or even just rapid acceleration/deceleration of the head, particularly in elderly patients. Elderly brains are atrophied, therefore when an elderly patient sustains head trauma, there is more space for the brain to move within the cranium, and more opportunity to tear the bridging veins. Remember that alcoholic patients have brain atrophy as well, making them more susceptible to SDH.
The bleeding from an SDH is venous, therefore symptoms may develop slowly over time, as in Noah’s patient. Morbidity comes from the pressure that the expanding hematoma puts on the rest of the brain. Once the hematoma is large enough, it will compress brain structures resulting in symptoms – most commonly unilateral weakness or hemiparesis (1). Decreased GCS is often seen with an acute, rapidly expanding SDH.
SDH can be classified as acute, subacute or chronic:
- Acute SDH – less than 24 hours
- Subacute SDH – between 24 hours and 2 weeks
- Chronic SDH – over 2 weeks
When is Neurosurgical Intervention Indicated?
We tend to get exasperated by our neurosurgical colleagues when they recite their mantra of “no acute neurosurgical intervention”. So let’s look at the actual indications for neurosurgical intervention in acute SDH (2):
- >10 mm thickness of the SDH
- >5 mm midline shift
- Worsening mental status after hospital admission i.e. a decrease of 2 or more on GCS scale
- Asymmetric pupils
- ICP >20 mm Hg
One thing to remember – a patient’s depressed GCS may not be due to the pressure from the SDH, but from swelling from direct brain tissue damage. Therefore, evacuating that hematoma may not actually be the correct decision. An appropriate course would be admission to an ICU setting with ICP monitoring – via ventriculostomy – and close neuro checks.
Just because your patient is not going for craniotomy immediately does not mean you are done. Don’t forget TBI basics:
- Elevate the head of the bed
- Avoid anything in (IJ line) or around (c-collar) the neck that will block venous drainage
- Keep MAP > 80 mm Hg
- Keep O2 saturation > 94%
- Keep Hgb > 7 g/dl
- Keep temperature below 100.4F
- Consider seizure prophylaxis – though no longer recommended by current guidelines (3)
- REVERSE ANTICOAGULATION
The treatment of chronic SDH with neurosurgery is more controversial and depends on symptoms and individual neurosurgeon practice.
For an in depth analysis on indications for neurosurgical intervention in ICH read Dr. Kim’s post – Cracking Skulls: When is Neurosurgical Intervention Helpful for ICH?
- Walls, Ron et al. Rosen’s Emergency Medicine, 9th Edition. Elsivier 2018.
- Bullock MR et al.Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58
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Hemphill JC et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/AmericanStroke Association. Stroke. 2015;46(7):2032–60.
Charles Murchison
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