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==Background==
==Background==
*Can present as acute (<14 days) and chronic (>14 days)
*Bleeding between the dura mater and arachnoid membrane, typically from bridging vein rupture
*Both types are caused by sudden acceleration-deceleration of the brain with resultant shearing of the bridging veins.
*Three types by timing:
**Blood pools between the dura mater and arachnoid
**Acute (<3 days) — hyperdense (white) on CT
*Patients with extreme atrophy are at increased risk (elderly, alcoholics)
**Subacute (3-21 days) — isodense (may be difficult to see)
**Patients less than 2 years old are also at increased risk
**Chronic (>21 days) — hypodense (dark) on CT
*SDH are often associated with other brain injuries
*Most common in elderly and anticoagulated patients<ref name="karibe">Karibe H, et al. Surgical management of traumatic acute subdural hematoma in adults. ''Neurol Med Chir (Tokyo)''. 2014;54(11):887-894. PMID 25367584.</ref>
*Acute SDH mortality: 50-90% (highest of all traumatic intracranial lesions)
*May occur with minimal or no trauma in the elderly and anticoagulated
 
==Risk Factors==
*Advanced age (cerebral atrophy stretches bridging veins)
*Anticoagulation / antiplatelet therapy
*Chronic [[Ethanol toxicity|alcohol use]] (cerebral atrophy, coagulopathy)
*Coagulopathy or thrombocytopenia
*Prior falls or head trauma (even minor)
*CSF shunt (overdrainage)


==Clinical Features==
==Clinical Features==
*Patients with acute SDH generally will present unconscious after a severe trauma
===Acute SDH===
*Patients with chronic SDH generally present with altered mental status or vague complaints
*Headache, altered mental status, decreasing [[GCS]]
*High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity
*Ipsilateral fixed/dilated pupil (uncal herniation)
*Contralateral hemiparesis
*May present with coma from onset
*Associated with high-energy mechanism or fall in anticoagulated patients
 
===Chronic SDH===
*Insidious onset over weeks to months
*Headache, cognitive decline, confusion, personality changes
*Gait disturbance, falls
*Fluctuating neurologic symptoms (may mimic [[Stroke (main)|stroke]] or [[Dementia|dementia]])
*History of trauma often absent or trivial


==Differential Diagnosis==
==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}
*[[Epidural hemorrhage]]
*[[Subarachnoid hemorrhage]]
*[[Intracerebral hemorrhage]]
*[[Stroke (main)|Ischemic stroke]]
*[[Meningitis]]
*[[Dementia]] (chronic SDH)


==Evaluation==
==Evaluation==
[[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]]
*Non-contrast CT head — test of choice<ref name="bullock2">Bullock MR, et al. Surgical management of acute subdural hematomas. ''Neurosurgery''. 2006;58(3 Suppl):S16-24. PMID 16710968.</ref>
{{Head trauma workup}}
**Acute: hyperdense, crescent-shaped collection crossing suture lines
*Noncontrast CT Brain is the gold standard
**Chronic: hypodense, crescent-shaped; may have mixed density if rebleeding
**Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance
**Evaluate for midline shift, mass effect, herniation
**Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
*Labs: CBC, coagulation studies (PT/INR, PTT), type and screen
**Contrasted studies are useful in distinguishing acute, subacute, and chronic
*If on anticoagulation: specific reversal levels (e.g., anti-Xa for DOACs)


==Management==
==Management==
*See [[Head trauma (main)]]
===Acute SDH===
*Emergent neurosurgical evacuation
*'''ABCs''' — intubate if GCS <=8
**Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)<ref>Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24</ref> <ref>Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9</ref>
*Emergent neurosurgical consultation
*Management of ICP
*'''Reverse anticoagulation''' immediately:
**Head of bed to 30 degrees
**Warfarin: 4-factor PCC (25-50 units/kg) + Vitamin K 10 mg IV
**Short-term use of hyperventilation
**Dabigatran: Idarucizumab 5 g IV
**Hyperosmolar agents ([[Mannitol]], 3% saline)
**Rivaroxaban/Apixaban: Andexanet alfa or 4-factor PCC
*[[Coagulopathy (Main)|Reversal of anticoagulation]]
**Antiplatelet agents: platelet transfusion if surgical candidate
*Treat and prevent hypotension and hypoxia
*ICP management: head of bed elevation, osmotherapy ([[Mannitol]] or [[Hypertonic saline]])
**Associated with significantly increased mortality<ref>Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.</ref>
*Surgical indications: clot thickness >10 mm, midline shift >5 mm, GCS drop >=2 points
*Emergency Department [[Burr hole]], if indicated
 
===Chronic SDH===
*Neurosurgical consultation for possible burr hole drainage
*Reverse anticoagulation
*Many small, asymptomatic chronic SDH may be observed with serial imaging
*Symptomatic chronic SDH: typically surgical (burr hole or craniotomy)


==Disposition==
==Disposition==
*Admission to NS or trauma surgery
*All acute SDH: admit, neurosurgical evaluation, ICU for operative or declining patients
*Chronic SDH: admit if symptomatic, new, or enlarging; small stable chronic SDH may have outpatient neurosurgery follow-up


==See Also==
==See Also==
*[[Intracranial Hemorrhage (Main)]]
*[[Epidural hemorrhage]]
*[[Head Trauma]]
*[[Head trauma (main)]]
 
*[[Subarachnoid hemorrhage]]
==External Links==
*[[Anticoagulation reversal]]
*[http://radiopaedia.org/articles/subdural-haemorrhage SDH Radiographs]


==References==
==References==
<references/>
<references/>


[[Category:Neurology]]
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Neurology]]

Revisión actual - 09:26 22 mar 2026

Background

  • Bleeding between the dura mater and arachnoid membrane, typically from bridging vein rupture
  • Three types by timing:
    • Acute (<3 days) — hyperdense (white) on CT
    • Subacute (3-21 days) — isodense (may be difficult to see)
    • Chronic (>21 days) — hypodense (dark) on CT
  • Most common in elderly and anticoagulated patients[1]
  • Acute SDH mortality: 50-90% (highest of all traumatic intracranial lesions)
  • May occur with minimal or no trauma in the elderly and anticoagulated

Risk Factors

  • Advanced age (cerebral atrophy stretches bridging veins)
  • Anticoagulation / antiplatelet therapy
  • Chronic alcohol use (cerebral atrophy, coagulopathy)
  • Coagulopathy or thrombocytopenia
  • Prior falls or head trauma (even minor)
  • CSF shunt (overdrainage)

Clinical Features

Acute SDH

  • Headache, altered mental status, decreasing GCS
  • Ipsilateral fixed/dilated pupil (uncal herniation)
  • Contralateral hemiparesis
  • May present with coma from onset
  • Associated with high-energy mechanism or fall in anticoagulated patients

Chronic SDH

  • Insidious onset over weeks to months
  • Headache, cognitive decline, confusion, personality changes
  • Gait disturbance, falls
  • Fluctuating neurologic symptoms (may mimic stroke or dementia)
  • History of trauma often absent or trivial

Differential Diagnosis

Evaluation

  • Non-contrast CT head — test of choice[2]
    • Acute: hyperdense, crescent-shaped collection crossing suture lines
    • Chronic: hypodense, crescent-shaped; may have mixed density if rebleeding
    • Evaluate for midline shift, mass effect, herniation
  • Labs: CBC, coagulation studies (PT/INR, PTT), type and screen
  • If on anticoagulation: specific reversal levels (e.g., anti-Xa for DOACs)

Management

Acute SDH

  • ABCs — intubate if GCS <=8
  • Emergent neurosurgical consultation
  • Reverse anticoagulation immediately:
    • Warfarin: 4-factor PCC (25-50 units/kg) + Vitamin K 10 mg IV
    • Dabigatran: Idarucizumab 5 g IV
    • Rivaroxaban/Apixaban: Andexanet alfa or 4-factor PCC
    • Antiplatelet agents: platelet transfusion if surgical candidate
  • ICP management: head of bed elevation, osmotherapy (Mannitol or Hypertonic saline)
  • Surgical indications: clot thickness >10 mm, midline shift >5 mm, GCS drop >=2 points

Chronic SDH

  • Neurosurgical consultation for possible burr hole drainage
  • Reverse anticoagulation
  • Many small, asymptomatic chronic SDH may be observed with serial imaging
  • Symptomatic chronic SDH: typically surgical (burr hole or craniotomy)

Disposition

  • All acute SDH: admit, neurosurgical evaluation, ICU for operative or declining patients
  • Chronic SDH: admit if symptomatic, new, or enlarging; small stable chronic SDH may have outpatient neurosurgery follow-up

See Also

References

  1. ↑ Karibe H, et al. Surgical management of traumatic acute subdural hematoma in adults. Neurol Med Chir (Tokyo). 2014;54(11):887-894. PMID 25367584.
  2. ↑ Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58(3 Suppl):S16-24. PMID 16710968.
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