QuestionSBA
QuestionChoice
Whilst trauma can cause subdural haemorrhages, the hyperdense (white) appearance suggests this is acute. Historical trauma would not account for an acute subdural haemorrhage.
10015759
d
Head trauma as a child
QuestionChoice
A ruptured aneurysm would most likely cause a subarachnoid haemorrhage, presenting as blood filling the basal cisterns on CT scan.
10015758
c
Berry aneurysm
QuestionChoice
This is unlikely to contribute to the development of a subdural haematoma.
10015757
b
Family history of Alzheimer's disease
QuestionChoice
Patients who are chronically hypertensive are prone to deep lacunar haemorrhages. There is no known association between subdural haemorrhages and hypertension.
10015760
e
Hypertension
QuestionChoice
The diagnosis from the scan is an acute subdural haematoma, which occurs when the bridging veins between the brain and saggital sinus rupture. Risk factors include older age and alcohol use, as these both cause brain atrophy, which stretches the veins.
10015756
a
Chronic alcohol use
QuestionComment
Chronic alcohol use over head trauma because they aren't elderly?
39643
QuestionComment
If it was a recent head trauma, then yes it would be relevant but it was chronic so unlikely to have caused the subdural bleed
39695
User
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Hippocampal Gal
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Supine Metabolism 
QuestionComment
'Historical' head trauma could mean that it happened a few hours ago though
40032
User
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Acute Botox
QuestionComment
I smell a rat 

40540
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QED
Concept
Chapter

### Summary

A subdural haematoma (SDH) is a neurological condition characterized by the accumulation of venous blood between the dura mater and arachnoid mater, often following minor trauma in elderly patients. It can present with a reduced Glasgow Coma Scale (GCS), and is commonly seen in patients with fluctuating GCS. Diagnosis is typically established through a CT scan, with the appearance of the clot varying based on its age. Management strategies largely depend on the stage of the haematoma, with craniotomy indicated for acute haemorrhages, and burr holes recommended for chronic haemorrhages.

### Definition

A subdural haematoma is characterised by the accumulation of venous blood in the potential space between the dura mater and arachnoid mater of the brain.

### Epidemiology

Subdural haematomas typically occur in elderly individuals, particularly those over 65 years of age. It is often a consequence of minor trauma, leading to shearing forces that tear bridging veins between the cortex and dura mater. Risk factors include:

- Advancing age (>65 years old)
- Bleeding disorders or anticoagulant therapy
- Chronic alcohol use
- Trauma.

### Aetiology

The haematoma results from shearing forces that tear the bridging veins between the cortex and dura mater. These forces commonly arise from minor head traumas but can also occur spontaneously in patients with bleeding disorders, anticoagulant therapy, or chronic alcohol use.

### Signs and Symptoms

Clinical presentation of a subdural haematoma varies but may include:

- Headache
- Nausea or vomiting
- Confusion
- Fluctuating GCS
- Behavioural change.


### Differential Diagnosis

Differential diagnoses for subdural haematoma include:

- Epidural haematoma: Characterized by a brief loss of consciousness, followed by a "lucid interval" and then rapid neurological deterioration.
- Traumatic brain injury: Symptoms may include headache, confusion, lightheadedness, dizziness, blurred vision, or tired eyes.
- Stroke: Presents with sudden numbness or weakness, especially on one side of the body, confusion, trouble speaking or understanding, trouble seeing in one or both eyes, and trouble walking, dizziness, or loss of balance or coordination.
- Dementia: Gradual cognitive decline without fluctuating GCS.
- Migraine: Recurrent headaches that might be accompanied by nausea, vomiting, and sensitivity to light and sound.

### Investigations

Diagnosis of a subdural haematoma is primarily established through a CT scan. 

The appearance of the clot varies based on its age:

- Hyperacute phase (<1 hour): The clot may appear isodense, with underlying cerebral oedema.
- Acute phase (<3 days): The clot appears as a crescent-shaped hyperdense extra-axial collection over the affected hemisphere.
- Sub-acute phase (3 days to 3 weeks): The clot appears more isodense compared to the adjacent cortex, making identification more difficult. Contrast-enhanced CT or MRI can aid identification. There may be associated mass effect causing midline shift and sulcal effacement.
- Chronic phase (>3 weeks): The haematoma appears hypodense relative to the adjacent cortex.

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Further investigations may include:

- Routine blood tests including FBC, Renal Profile, Liver Function Tests
-  Clotting profile (to assess for coagulopathy)

### Management

Management of a subdural haematoma depends on the stage, patient’s premorbid baseline, and functional status. Many cases are managed conservatively, especially if there is no midline shift or cerebral oedema. However, for more severe cases, neurosurgical referral is required.

- **Conservative management**: If no significant midline shift or cerebral oedema.
	- For patients taking the DOAC dabigatran, Idarucizumab is a licensed NICE-approval reversal agent which can be given.
- **Surgical management**: In cases where intervention is necessary, options include:
  - **Craniotomy**: Typically for acute haemorrhages.
  - **Burr holes**: Typically for chronic haemorrhages.

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A subdural haemorrhage.
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Acute on chronic subdural haemorrhage
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A 42-year-old man has a CT head to investigate acute confusion and left-sided weakness. The scan shows a crescentic hyperdense area around the brain on the right-hand side.

Given the most likely diagnosis, which aspect of his history is likely to have contributed to his condition?
a