Subdural Haematoma

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------------------------------------------------------------------------------------------------------------------------------------------------------ In response to commonly asked questions, the Brain and Spine Foundation Helpline has compiled information sheets such as this one on several topics which are not covered in our current booklets. For further information and support, call the Brain and Spine Foundation’s free helpline on 0808 808 1000, email [email protected] or visit www.brainandspine.org.uk.

Subdural haematoma A Brain and Spine Helpline information sheet

What is a subdural haematoma? A Subdural haematoma is a collection of blood between the skull and the brain. The brain is surrounded by three tough membranes or dura. These membranes are called the meninges, the outermost membrane is called the dura mater, then the arachnoid and then the pia mater. The space between the two outer membranes (the dura mater and arachnoid) is called the subdural space. If a blood vessel within this space is damaged, blood can leak out and cause a clot to form, this is called a sub-dural haematoma. Subdural haematoma’s are classed as chronic or acute based on the time interval between injury and the onset of signs and symptoms.

How are subdural haematomas caused? They are often caused by trauma to the head or can be associated with anti-coagulant (blood thinning) medication such as Warfarin.

What are the symptoms? The skull is like a closed box and the brain fits very snugly within this box. As the blood clot forms it takes up room squashing the brain which in turn causes the pressure within the skull (intracranial pressure) to increase. This increase in pressure can affect the structure and function of the brain. Symptoms such as drowsiness, headaches, confusion, limb weakness and visual problem begin to show.

The different types of subdural haematomas There are different types of subdural haematomas and we describe them briefly here, however, it is important to note that the symptoms associated with all types are all very similar:

Acute subdural - onset of symptoms usually within 48 hours after injury. Chronic subdural – symptoms can occur between 2 weeks and several months after the initial injury. They are most common in elderly people, this is because the brain shrinks as we get older, causing greater free space between it and the skull, therefore, it takes longer for the blood clot to squash the brain and cause any symptoms. Because of the time lapse between the initial trauma and

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the onset of symptoms there may be a delay in diagnosis and it can often be difficult to relate it to an incident which may have happened several weeks previously. The development of a subdural haematoma in older people can also be related to the use of anti-coagulant medication such as warfarin. If the clotting function of the blood is unstable it can prevent a bleed from clotting and thus cause a large clot to form. Extra dural haematoma - This term refers to bleeding between the inner skull and the dura mater (the outermost layer of the three layers covering the brain). The cause is usually head trauma, sufficient to tear blood vessels directly beneath the skull. Symptoms are often more immediate after the trauma and the deterioration rapid. Extra dural haematoma’s are more common in younger people, especially young men, this is because young men tend to partake in more high risk activities than women.

Diagnosis and treatment of subdural haematoma Diagnosis is made based on clinical history and by a computerised tomography scan (CT). If the subdural haematoma is small and the symptoms are not severe it may be left to reabsorb by itself with no surgical intervention. During this time the patient would be carefully monitored for any deterioration.

If symptoms are severe, such as decreased level of consciousness, confusion etc, surgical intervention may be required. This can be done in two ways, either by a burr hole or craniotomy. Burr holes are holes drilled through the skull over the area of the bleed which allow the haematoma to be ‘sucked’ out. The procedure requires a small incision through the skin which is closed by a few stitches or staples. Burr holes are less invasive than a craniotomy and are often used for an acute subdural haematoma’s as the blood tends to be more ‘runny’ before it has clotted too much. A craniotomy is a larger opening in the skull and allows greater access to the brain. This method is more frequently used to remove chronic subdural haematomas as over time the blood will have become more solid and therefore is difficult to be ‘sucked’ out through a burr hole. There is more information about the procedure in our fact sheet entitled Craniotomy. Following both procedures the patient will be closely monitored and regular neuro observations performed. The reason for this is to check the person’s conscious level, it involves the nurses shining a light in the eyes, testing strength of arms and legs and also asking simple questions such as name and age. From these observations a Glasgow Coma Score (GCS) is recorded, any decrease in this score may indicate that the clot was reforming or the brain was being compromised in some

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way. A patient who has a subdural haematoma is often nursed lying flat, this aims to prevent the recollection of the blood which can occasionally happen if the original site of rupture has not healed. This can occur particularly in the case of elderly patients who have sustained a chronic subdural haematoma. The patient may also have a drip (intravenous fluids) to maintain hydration and will be given pain killers for any headaches they may be experiencing.

Recovering from a subdural haematoma Patients are often discharged home within a few days following treatment, once their neurological observations are stable and the Dr’s are confident there will be no further collection of the blood clot. It is normal to feel very tired and have slight headaches, however, if the patient becomes overly drowsy (difficult to wake up), nauseas, confused, develops visual problems or a weak arm/leg then is essential to contact your doctor again and another CT scan is likely to be performed.

Recovery is a very individual process and some people take longer than others. It is important to ‘take things easy’ and not push yourself too hard. It often helps if you can drink plenty of caffeine free drinks (at least 2 – 3 litres a day) as this helps the blood circulation within the brain and prevents it becoming dehydrated which can lead to headaches. It is also a good idea to take regular short relaxation periods of approximately 30 minutes, away from any stimulation (such as the television/radio etc) as this can help the brain to totally rest. Most people find they are ready to return to work within a few weeks following the bleed or you may be advised to wait until you have seen your consultant in the out patients department, this is usually within a month or two. In cases where the haematoma has caused severe damage to the brain the patient may need more intensive support, such as neuro rehabilitation involving physiotherapists, occupational therapists and speech therapists. Recovery following such a severe injury can be a long process and can result in more permanent deficits, such as limb weakness, personality changes, memory problems etc and individuals may need long term care.

Subdural Haematoma

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