Overview

The brain, an intricate web of thoughts and actions, is safeguarded by layers of protection within the skull. However, there are times when unexpected occurrences, such as Subdural haemorrhage (SDH), disrupt this protective barrier and pose serious risks to our well-being. In simpler terms, SDH is a condition where bleeding occurs between the brain and its outermost covering, the dura mater, leading to a buildup of blood that can exert pressure on the brain.

What is Subdural Haemorrhage?

Subdural haemorrhage, or subdural hematoma, is a medical condition characterised by the accumulation of blood between the brain's outer covering (dura mater) and the middle layer (arachnoid mater). This condition typically results from head injuries or trauma, where blood vessels between the brain's surface and the dura mater are damaged, leading to bleeding. Subdural haemorrhages can exert pressure on the brain, causing symptoms such as headache, confusion, weakness, and, in severe cases, unconsciousness. Prompt medical attention and, in some cases, surgical intervention may be necessary to alleviate the pressure and prevent further complications associated with subdural haemorrhages.

Causes of Subdural Haemorrhages:

SDH can be acute (fresh, developing in a few days) or chronic ( developing over weeks). Chronic SDH (CSDH) often arises from minor head injuries that might seem insignificant at the time. Picture this: a fall, a bump on the head from a low-height accident, or even a mild blow during sports—these seemingly harmless incidents can later manifest as CSDH. The brain, cushioned by cerebrospinal fluid, can experience a tear in blood vessels due to sudden movement or impact. This tear might not immediately cause symptoms, but over time, blood accumulates, creating pressure on the brain.

Moreover, certain risk factors can predispose individuals to CSDH. Advanced age, where brain atrophy causes the brain to shrink and stretch blood vessels, can make older adults more susceptible. Additionally, conditions like alcoholism, blood-thinning medications, or a history of repeated head injuries increase the risk of CSDH. When SDH develops membranes inside, microbleeds happen frequently, and chronic SDH also gets fresh (acute) blood components.

Recognising the Symptoms of Subdural Haemorrhages:

Symptoms of CSDH might not appear immediately after the injury, often taking days or weeks to manifest. The delayed onset can make it challenging to link these symptoms to an earlier head injury. Some of the common symptoms include

- Headaches: Persistent and worsening headaches are a prominent symptom. They might start mildly and gradually intensify.
- Confusion or changes in behaviour: Cognitive changes like confusion, memory loss, or difficulty concentrating might arise.
- Nausea and vomiting: These symptoms, especially when accompanied by headaches, can signal CSDH.
- Weakness or numbness: Sensory changes might occur, such as weakness or numbness in specific body parts.

It’s crucial to seek immediate medical attention if you or someone you know experiences these symptoms after a head injury, especially if they worsen over time.

Subdural Haemorrhages Diagnosis and Treatment:

Upon suspecting SDH, a doctor might recommend various diagnostic tests. A neurological exam can assess reflexes, coordination, and overall brain function. Imaging studies like CT scans or MRIs help visualise the brain and the presence of blood buildup, aiding in a definitive diagnosis.

Treatment options for SDH depend on the severity and symptoms. In mild cases, where the bleed is small and asymptomatic, the doctor might adopt a wait-and-watch approach, as the body can naturally absorb small amounts of blood over time.

However, surgical intervention becomes necessary when symptoms are present, or the bleeding is larger. A procedure called mini craniotomy and evacuation of hematoma involves making a small bone opening in the cranial vault to drain the accumulated blood and relieve pressure on the brain. At the same time, the endoscope is used to visualise the entire brain surface and remove membranes. It also helps with the control of bleeding vessels and membranes. Usually, a tiny tube or drain might be left in place temporarily to facilitate further drainage for a few days. This technique is very effective in reducing the recurrence of hematoma and has excellent results. In contrast, a burr hole ( small hole in the skull) allows only drainage of liquid blood, but the membranes remain, which results in recurrence.

Subdural Haemorrhages Recovery and Outlook:

Recovery from SDH varies from person to person. Factors such as age, overall health, and the severity of the bleeding influence the recovery process. Some individuals might experience full recovery within a few weeks post-surgery, while others might require more time for rehabilitation.

Physical therapy, occupational therapy, and cognitive rehabilitation might be recommended to aid recovery. These therapies focus on regaining strength, relearning skills, and improving cognitive functions affected by the bleed.

Written and Published by Dr. Utkarsh Bhagat

Conclusion

Subdural Hemorrhage, though a potentially serious condition, can be managed effectively with prompt medical attention. Understanding its causes, recognising the symptoms, and seeking timely treatment are crucial to ensuring a positive outcome. Remember, even seemingly minor head injuries warrant attention, and any unusual symptoms following such incidents should not be ignored.

If you or someone you know experiences symptoms suggestive of SDH after a head injury, don’t hesitate to seek medical advice promptly. We can effectively address and manage conditions like Subdural Hemorrhage through awareness and timely intervention.

Case Example

Preoperative MRI Brain ( Red arrows show mixed fresh and old blood on the surface of the brain , Green arrows show membranes in the collected blood)

Postoperative CT Scan ( Shows good evacuation of blood from the surface of the brain)

Case details

55 years, male
History of slip and fall two months back.
CT Scan on the day of injury was normal.
He developed a headache which gradually became very severe.
No improvement with medication.
Got MRI done, which showed Subdural hematoma.
Underwent Endoscopic evacuation of hematoma.
The endoscope helps visualise hidden corners and better removal of membranes.
Proven to reduce chances of recurrence of hematoma.
The patient improved dramatically and was discharged in 2 days.
Back to normal life, no headache now.

FAQs

Q. What causes a subdural haemorrhage? A. A subdural haemorrhage is often caused by head trauma or injury, such as a fall, car accident, or blunt force trauma to the head. The force of impact can damage blood vessels between the brain's surface and the dura mater, leading to bleeding.

Q. What are the common symptoms of a subdural haemorrhage? A. Symptoms may include headache, confusion, dizziness, nausea, vomiting, weakness, seizures, and changes in consciousness. Severe cases can lead to unconsciousness and neurological deficits.

Q. How is a subdural haemorrhage diagnosed? A. Diagnosis typically involves a neurological examination, medical history assessment, and imaging tests such as CT scans or MRI to visualise the bleeding and assess its extent.

Q. What are the treatment options for subdural haemorrhage? A. Treatment may involve close observation, medications to manage symptoms and reduce intracranial pressure, or surgical intervention to drain the accumulated blood and repair damaged blood vessels.

Q. What is the prognosis for individuals with a subdural haemorrhage? A. The prognosis varies depending on the severity of the haemorrhage and the timeliness of treatment. Mild cases may resolve with conservative management, while more severe cases may have long-term neurological consequences if not treated promptly. Early intervention is crucial for better outcomes.