SUBDURAL
HEMATOMA
P.AGUS EKA WAHYUDI
Definition
A Subdural hematoma (SDH) is a collection of blood below the inner layer of the
dura but external to the brain and arachnoid membrane.
Classification
Acute subdural hematoma – the manifestations appear during the first 3 days
Subacute subdural hematoma – clinically manifests between 4 and 21 days
Chronic subdural hematoma – the clinical manifestations appear after 21 days
Etiology
Head trauma
Coagulopathy or medical anticoagulation ( warfarin, heparin, hemophilia, liver
disease, Thrombocytopenia.
Non Traumatic Intracranial hemorrhage due cerebral aneurysm, arteriovenous
malformation or tumor ( Meningioma or dural metastases)
Post surgical ( Craniotomy, CSF Shunting)
Intracranial hypotension ( after lumar puncture, lumbar CSF Leak,
Lumboperitoneal shunt, Spinal epidural anesthesia)
Child abuse or shaken baby syndrome
Spontaneous or unknown (rare)
Risk factors of chronic SDH
Chronic alcoholism
Epilepsy
Coagulopathy
Arachnoid cyst
Anticoagulant therapy (including aspirin)
Cardiovascular disease (eg, hypertension, arteriosclerosis)
Thrombocytopenia
Diabetes mellitus
Epidemiology
Acute SDH occur in 5-25% of patients with severe head injury
Chronic SDH reported 1-5.3 cases/ 100.000 population
Medium age of patients with chronic subdural haematoma is of 63 yo
Male population is more frequently affected – 64% vs. 33%
Clinical diagnosis
History taking Clinical Presentation
Decrease level of consciousness
Falls Headache
Violence Difficulty with gait and balance
Cognitive dysfunction or memory loss
Motor vehicle accident
Personality change
Motor deficit ( Hemiparesis)
Aphasia
Severe pain accompanied nausea and vomiting
Weakness, seizures and incontinence
Hemiparesis ipsilateral to the hematoma in 40% case.
Gait dysfunction
Clinical diagnosis
Chronic SDH
Neurologic examination for chronic subdural hematoma may demonstrate any of the following [29] :
Mental status changes
Papilledema
Hyperreflexia or reflex asymmetry
Hemianopsia
Hemiparesis
Third or sixth cranial nerve dysfunction
Such findings may also be associated with other entities. In patients aged 60 years or older, hemiparesis and
reflex asymmetry are common presenting signs. In patients younger than 60 years, headache is a common
presenting symptom.
Differential diagnoses
Dementia
Stroke
Transient Ischemic attack
Tumor
Subarachnoid hemorrhage
Meningitis
Encephalitis
imaging studies
Acute SDH
imaging studies
Subacute SDH
imaging studies
Chronic
SDH
Management
Minimal craniotomy (trephination) - is one of the most often used surgical
techniques in cases of current chronic subdural haematomas. According to a
national Canadian study in 2005, 85% of the respondents have indicated this
technique as the most commonly used as initial surgical treatment.
It is usually done under general anesthesia, some surgeons preferring only one
trephination, others two
Tehnik operasi
Pasien posisi supine kepala miring ke kanan dalam GA OTT
Asepsis lapangan operasi persempit dengan doek steril
Incisi question mark ekspos cranium
Burr hole 6 hole sambungkan dengan gigli saw tampak dura warna gelap
Krabbite pada ridge perdarahan , gantung dura keliling
Evaluasi isi kapsul warna merah gelap, berupa clot busa
Pisahkan keseluruhan kapsul dengan hati-hati
Insisi pada abdomen hingga fascia, insisi tulang, tutup
Jahit luka primer, tight
Jahit fascia otot temporalis
Pasang drain, fiksasi tulang
Jahit luka lapis demi lapis
Perawatan Pascabedah
Monitor kondisi umum dan neurologis pasien dilakukan seperti biasanya. Jahitan
dibuka pada hari ke 5-7. Tindakan pemasangan fragmen tulang atau kranioplasti
dianjurkan dilakukan setelah 6-8 minggu kemudian.
Refferences
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556906/
https://emedicine.medscape.com/article/1137207-overview
Marks S. Greenberg : Handbook of Neurosurgery; 6th ed.
Schwartz’s : Principles of Surgery;9th Ed, 2010
