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Subdural Hematoma: Causes, Symptoms and Treatment

A subdural hematoma is a collection of blood between the brain and the dura mater. It usually results from head injury and can be life-threatening.

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Things worth knowing about "Subdural Hematoma"

A subdural hematoma is a collection of blood between the brain and the dura mater. It usually results from head injury and can be life-threatening.

What is a Subdural Hematoma?

A subdural hematoma is a buildup of blood in the subdural space – the gap between the tough outer membrane of the brain (dura mater) and the middle membrane (arachnoidea). It most commonly occurs when bridging veins connecting the brain to the venous sinuses are ruptured, typically as a result of head trauma. The accumulated blood creates pressure on brain tissue, which can lead to serious neurological complications.

Types of Subdural Hematoma

There are three main types:

Acute subdural hematoma: Develops within hours of a severe traumatic brain injury. It is a medical emergency with a high mortality rate.
Subacute subdural hematoma: Develops over several days to weeks after head trauma. Symptoms appear with a delay.
Chronic subdural hematoma: Accumulates slowly over weeks to months, often following a minor or even unnoticed head injury. It is more common in elderly individuals and those taking blood thinners.

Causes

The most common causes of subdural hematoma include:

Falls with head impact (especially in older adults)
Traffic accidents and sports injuries
Violent head shaking (e.g., shaken baby syndrome in infants)
Use of anticoagulant medications (e.g., warfarin, aspirin, or newer oral anticoagulants)
Chronic alcohol use (brain atrophy increases risk)
Brain tumors or vascular malformations (less common causes)

Symptoms

Symptoms vary depending on the type and severity of the bleeding:

Headache (often the first sign)
Nausea and vomiting
Altered consciousness or coma
Speech difficulties (aphasia)
Weakness or paralysis on one side of the body (hemiparesis)
Unequal pupil sizes (anisocoria)
Confusion and personality changes (especially in chronic cases)
Balance and gait disturbances

Diagnosis

Diagnosis is confirmed through imaging studies:

Computed Tomography (CT scan): The standard method in emergency settings. Shows the blood collection as a characteristic crescent-shaped density along the inner skull.
Magnetic Resonance Imaging (MRI): Provides more detailed information, particularly useful for diagnosing chronic subdural hematomas.
Neurological examination and medical history assessment to evaluate the severity of symptoms.

Treatment

Conservative Management

Small, clinically stable subdural hematomas – particularly in the chronic form – may be managed with close monitoring and medication adjustment. This includes observation, blood pressure management, and modification or discontinuation of anticoagulant therapy.

Surgical Treatment

Larger or symptomatic hematomas require neurosurgical intervention:

Burr hole drainage: In chronic subdural hematoma, the liquefied blood is drained through one or two small holes drilled into the skull.
Craniotomy: In acute subdural hematoma, open surgery involving the removal of a section of the skull may be necessary to evacuate the clot and stop active bleeding.

Prognosis

The outlook depends on the type and size of the hematoma, the age of the patient, and how quickly treatment is initiated. Acute subdural hematoma carries a serious prognosis, with mortality rates of up to 50–90% in severe cases. Chronic subdural hematoma, when detected early and treated surgically, often has a favorable outcome with full recovery possible in many patients.

References

Greenberg, M. S. - Handbook of Neurosurgery. 9th Edition. Thieme, 2019.
German Society of Neurosurgery (DGNC) - Clinical Guideline: Chronic Subdural Hematoma, AWMF Registry No. 008-002 (2022).
Adhiyaman, V. et al. - Chronic subdural haematoma in the elderly. Postgraduate Medical Journal, 2002; 78(916): 71-75.

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