Subdural hematoma

Generality

A subdural hematoma is a blood spill in the space between the outermost meninge (dura mater) and the middle meningin (arachnoid).

Generally, the origin of the episodes of subdural hematoma are head traumas, following car accidents, falls from great heights or violent attacks.

The typical symptoms are: headache, confusion, malaise, unconsciousness and mood swings.

For an accurate diagnosis, it is essential: the physical examination, the medical history and the CAT scan of the brain.

Treatment is usually surgical and involves removing the blood spill.

Only if the subdural hematoma is small, it is possible to wait for spontaneous healing, without resorting to surgery.

Short review of the meninges

In number of three, the meninges are the lining membranes of the organs of the central nervous system (CNS), ie the brain and the spinal cord.

Figure: an overview of the brain areas .

Their precise location is between the encephalic matter (in the case of the brain) or medullary (in the case of the spinal cord) and the bone lining (skull or vertebral column), which protects the main structures of the central nervous system.

Proceeding from the outside towards the inside, the three meninges are:

• The dura mater . Very thick membrane, it contains an intricate network of venous vessels, which, through the venous sinuses, provide drainage of the blood circulated in the CNS.

  The dura mater of the brain is slightly different from the dura mater of the spinal cord.

  The first has two laminae, one that acts as a periosteum and one that passes over the convolutions of the brain.

  The second has the shape of a hollow cylinder and is separated, with respect to the vertebrae, from an area rich in adipose tissue and venous blood vessels; this area is called a perdural space or epidural space .

• The arachnoid . Looking like a spider's web, it is the middle bitch. To separate it from the outermost meninge is a space called subdural space ; to divide it, instead, from the innermost meninge is a space known as the subarachnoid space .

  In the subarachnoid space lies part of the cerebrospinal fluid (which is the substance taken at the time of the lumbar punctures).

• The pious mother . Very thin and in direct contact with the brain and spinal cord, it contains the arteries that supply the central nervous system.

What is a subdural hematoma?

Subdural hematoma is the medical term for a blood spill in the subdural space of the brain, that is, in the space between the brain arachnoid and the encephalic dura mater.

SYNONYMS

In medicine, the subdural hematoma is also known as subdural hemorrhage .

Causes

A subdural hematoma is formed when one or more blood vessels, present in the subdural space, break, causing blood to leak (hemorrhagic stroke).

The main causes of subdural hematoma are traumatic head injuries (or head injuries ), which can occur in situations such as, for example, car accidents, falls from great heights, violent acts of aggression or sports injuries to the head.

RISK FACTORS

Anyone can develop a subdural hematoma, following a head injury.

However, there are some categories of people more at risk than others.

Among the individuals most at risk of subdural hematoma, we note:

• Newborns . The blood vessels of the brain of newborns are still very fragile. Therefore, they can break if the infants are victims of shaking a little too energetic.

  In this regard, it is worth remembering that the subdural hematoma is a typical consequence of the childhood condition known as shaken baby syndrome .

• The elderly . Aging is the cause of brain atrophy, a condition that weakens the structures of the brain, including blood vessels.

  The weakening of the encephalic blood vessels, which derives from brain atrophy, causes a subdural hematoma to appear even after minor head injuries.

• Alcoholics . Like aging, alcoholism also causes brain atrophy and a brain vascular system more prone to damage.
• Those who continuously take anticoagulant drugs, such as warfarin or aspirin. By diluting the blood, these medicines predispose to blood loss, even when the blood vessels are subject to small lesions.

  In general, people who take anticoagulants regularly tend to be subject to hematoma, bleeding, etc.

Symptoms, signs and complications

The symptomatology of the subdural hematoma depends, mainly, on the compression that the blood spill exerts on the portion of the encephalon involved.

The typical symptoms of a subdural hematoma are:

• Headache that tends to get worse;
• Sense of malaise;
• Confusion;
• Sudden changes in personality and mood swings;
• Drowsiness;
• Loss of knowledge.

OTHER SYMPTOMS

Other clinical manifestations of subdural hematoma are:

• Dizziness and / or dizziness;
• Amnesie;
• Lethargy or weakness;
• Nausea and vomit;
• Loss of appetite;
• Inability to speak;
• Ataxia and walking problems;
• Loss of motor control;
• Breath changes;
• Tinnitus;
• Blurred vision.

WHEN TO REFER TO THE DOCTOR?

Head injuries such as to cause a medium-large subdural hematoma fall, in their own right, among medical emergencies .

A medical emergency is a condition that requires immediate health care. Otherwise, the patient is in serious danger.

COMPLICATIONS

Failure to treat a subdural hematoma involves, first, its expansion and a worsening of the already present symptoms; therefore, secondly, it can be the cause of coma or death.

Diagnosis

In general, the diagnostic procedure that allows the identification of a subdural hematoma includes the physical examination, the anamnesis and the CT scan of the brain or, as an alternative to the latter, the nuclear magnetic resonance of the brain.

OBJECTIVE AND ANAMNESIS EXAMINATION

The objective examination is the set of diagnostic "maneuvers", carried out by the doctor, to verify the presence or absence, in the patient, of signs indicative of an abnormal condition.

In case of suspected subdural hematoma, the most classic of objective examinations consists of: searching for signs of trauma to the head, examining the pupils' response to light, assessing the state of consciousness and so on.

Turning then to the anamnesis, this last is the collection and the critical study of the symptoms and the facts of medical interest, denounced by the patient or his relatives (NB: the relatives are involved, above all, when the patient is small).

In case of suspected subdural hematoma, the most classic of the anamnesis is able to reveal the possible triggering factors and risk conditions.

TAC

The brain CT scan is a radiological exam that provides clear images of the encephalic compartment. Although painless, it is a minimally invasive method, since its execution exposes the patient to a non-negligible dose of ionizing radiation harmful to humans.

Therapy

Unless it is small, subdural hematoma is a condition that requires surgery.

The surgical procedure for the elimination of a subdural hematoma is usually entrusted to a neurosurgeon .

SURGICAL TREATMENT

Currently, to treat the subdural hematoma, there are two different surgical approaches: the craniotomy and the drilling of the skull.

• Craniotomy . It is the most indicated approach, when the subdural hematoma is subsequent to severe cranial trauma. Its realization foresees the temporary removal of the portion of skull below which the blood spillage lies, so as to eliminate the latter quite easily. To facilitate the welding of the portion of skull removed temporarily, the operating neurosurgeon uses screws and pins; screws and pins which will then be removed a few weeks after surgery.
• Drilling of the skull . It is the most indicated approach, when the subdural hematoma is consequent to mild cranial traumas. Its execution involves the practice of a hole on the skull and the insertion, in this hole, of a tube, through which the neurosurgeon aspirates the blood spill.

Like all surgery, surgery to remove a subdural hematoma can also lead to complications. Among the complications that may arise from the surgical removal of a subdural hematoma are:

• Cerebral hemorrhage;
• Development of an infection at the surgical incision level;
• Deep venous thrombosis;
• Stroke;
• Convulsions.

Furthermore, it is possible that the surgical intervention is partially effective, in the sense that, at its conclusion, a more or less conspicuous part of the subdural hematoma may still exist. In these situations, the only solution is to repeat the operation, in the hope, this time, of completely removing the blood spill.

RECOVERY TIME, AFTER THE SURGERY

Recovery times, after surgery to eliminate a subdural hematoma, vary from subject to subject, based on: the size of the blood supply, the timeliness with which the patient has been provided with relief and his condition. health at the time of the event triggering the subdural hematoma.

For some individuals, recovery can occur in a few weeks; for other individuals, however, it can take several months.

The intervention of physiotherapists, speech therapists and occupational therapy experts is fundamental during the recovery period.

WHAT TO DO IN THE CASE OF HEMATOMA SUBDURAL OF SMALL DIMENSIONS

If the subdural hematoma is small, there is a good chance that it will heal spontaneously, without the use of particular therapies. Therefore, in such circumstances, doctors choose to monitor the situation, ready to intervene in the face of a failed recovery or a deterioration.

Prognosis

The prognosis in case of subdural hematoma depends mainly on two factors: the severity of the blood spill and the patient's health conditions at the time of the head injury.

As far as the severity of the blood spill is concerned, the more serious a subdural hematoma is, the higher the probability that the prognosis is unfavorable; on the contrary, the more a subdural hematoma is contained in its extension, the greater the chances of a favorable prognosis.

As for the patient's health conditions at the time of the head injury, the most life threatening subjects are the elderly, very young children, alcoholics and those who, for some reason, suffer from bleeding disorders.

Prevention

Fastening seat belts and wearing specific helmets during work activities or certain sports at risk of head trauma are among the main countermeasures, recommended by doctors, to reduce the risk of subdural hematoma.