QuestionSBA
QuestionChoice
There should be suspicion of a previously unwitnessed fall due to the presence of bruising along the patient's arm and reported low staffing levels by the carer. Unwitnessed falls can lead to head injury. The elderly are at higher risk of subdural haematomas after head injury due to brain atrophy stretching the bridging veins within the subdural space. Therefore, this presentation likely represents a subdural haematoma. A CT head can be used to confirm the diagnosis; the patient will have a crescent-shaped mass.
52862
a
Subdural haematoma
QuestionChoice
Extradural haematomas typically present after a head injury with a blow to the temples resulting in rupture of the middle meningeal artery. There is typically an initial loss of consciousness, followed by a period of lucidity then rapid decline in conscious level. There are no clinical features to suggest an extradural haematoma. The CT head would show a convex-shaped mass.
52864
c
Extradural haematoma
QuestionChoice
A subarachnoid haemorrhage would typically present with sudden-onset thunderclap headache and rapid clinical deterioration. Given the suspicion of a fall and the subacute presentation, a subdural haematoma is more likely in this age group due to brain atrophy and bridging vein tethering.
52865
d
Subarachnoid haemorrhage
QuestionChoice
Urinary tract infections (UTIs) can cause acute confusional states (delirium). This patient is presenting acutely confused; therefore, it is a diagnosis worth considering. However, there are no clinical features of UTI in either the history (such as dysuria, frequency or urgency), or examination (such as fever or suprapubic pain). This makes a UTI unlikely.
52863
b
Urinary tract infection
QuestionChoice
Normal pressure hydrocephalus is a possible differential for the falling and confused patient. These patients are typically described as 'wet, wobbly and weird', relating to urinary incontinence, ataxia and confusion respectively. However, there is an absence of these features in the clinical history and a subdural haematoma is a diagnosis to exclude first.
52866
e
Normal pressure hydrocephalus
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.

[lightgallery]

[lightgallery1]

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.

186
Picture
A subdural haemorrhage.
945
Subdural.jpeg
images/2jkcw7l91665036171691.jpg
images/2jkcw7l91665036171691_256.jpg
images/2jkcw7l91665036171691_512.jpg
1fcJBgA3LLloeBcKlYxmdLdYYfOMm/g=
Picture
Acute on chronic subdural haemorrhage
62
acuteChronicSubdural.png
images/210mu8h11548086881678.jpg
images/210mu8h11548086881678_256.jpg
images/210mu8h11548086881678_512.jpg
GwgKBgAIN2iGeDgniIiIdYdIAAAAAAA=
Topic
19
Radiology
189
Subdural Haemorrhage
Topic
34
Neurology
Video
Concept
189
Subdural Haemorrhage
165
ncKMYZA
images/videos/neurology.png
Haemorrhagic stroke
10633
Elderly patients are at increased risk of subdural haematomas due to brain atrophy, often following unwitnessed falls and resulting head injuries.
An 83-year-old man with mild vascular dementia is brought to A&E by one of his carers. They report that he has not been himself for the past few weeks. He was previously independent with his activities of daily living but is now unable to feed or dress himself due to increasing confusion. This morning he was found to be very drowsy and withdrawn during breakfast. The carer admits that over the past few weeks they have been understaffed due to staff sickness. On examination, there is fading bruising along his left arm and shoulder. 

What is the most likely explanation for his presentation?
a