What is Subdural Hematoma

A subdural hematoma is a collection of blood between the brain and its outer covering (dura). As the amount of blood increases, pressure builds on the brain.

There are two types of subdural hematomas.

• Acute. This type develops shortly after a hard, direct hit to the head and causes blood to collect very quickly. This is a medical emergency. If it is not diagnosed and treated quickly, it can lead to severe brain injury or death.
• Chronic. This is when bleeding develops more slowly, over weeks or months. In some cases, this type does not cause symptoms.

What are the causes?

This condition is caused by bleeding (hemorrhage) from a broken (ruptured) blood vessel. In most cases, a blood vessel ruptures and bleeds because of injury (trauma) to the head, such as from a hard, direct hit. Head trauma can happen in:

• Traffic accidents.
• Falls.
• Assaults.
• Sports injuries.

In rare cases, a hemorrhage can happen without a known cause (spontaneously), especially if you take blood thinners (anticoagulants).

What increases the risk?

This condition is more likely to develop in:

• Older people.
• Infants.
• People who take blood thinners.
• People who have head injuries.
• People who abuse alcohol.

What are the signs or symptoms?

Symptoms of this condition can vary depending on the size of the hematoma. Symptoms can be mild, severe, or life-threatening. They include:

• Headaches.
• Nausea or vomiting.
• Changes in vision, such as double vision or loss of vision.
• Changes in speech or trouble understanding what people say.
• Loss of balance or difficulty walking.
• Weakness, numbness, or tingling in the arms or legs, especially on one side of the body.
• Fits of movements that you cannot control (seizures).
• Change in personality.
• Increased sleepiness.
• Memory loss.
• Loss of consciousness.
• Coma.

Symptoms of acute subdural hematoma can develop over minutes or hours. Symptoms of chronic subdural hematoma may develop over weeks or months.

How is this diagnosed?

This condition is diagnosed based on the results of:

• A physical exam.
• Tests of strength, reflexes, coordination, senses, manner of walking (gait), and facial and eye movements (neurological exam).
• Imaging tests, such as MRI or CT scan.

How is this treated?

Treatment for this condition depends on which type of hematoma you have and how severe it is.

Treatment for acute hematoma may include:

• Emergency surgery to drain blood or remove a blood clot.
• Medicines that help the body get rid of excess fluids (diuretics). These may help to reduce pressure in the brain.
• Assisted breathing (ventilation).

Treatment for chronic hematoma may include:

• Observation and bed rest at the hospital.
• Emergency surgery.

If you take blood thinners, you may need to temporarily stop taking them. You may also be given antiseizure (anticonvulsant) medicine

Sometimes, no treatment is needed for chronic subdural hematoma.

Follow these instructions at home:

Activity

• Avoid any situation where there is potential for another head injury, such as competitive sports, downhill snow sports, and horseback riding. Do not do these activities until your health care provider approves.
  • Wear protective gear, such as a helmet, when participating in activities such as biking or contact sports.
• Avoid excessive visual stimulation while recovering. This means limiting how much you read and limiting your screen time on a smart phone, tablet, computer, or TV.
• Rest as told by your health care provider. Rest helps the brain to heal.
• Try to avoid activities that cause physical or mental stress. Return to work or school as told by your health care provider.
• Do not drive, ride a bicycle, or use heavy machinery until your health care provider approves.
• Do not lift anything that is heavier than 5 lb (2.3 kg), or the limit you are told, until your health care provider approves.

Alcohol use

• Do not drink alcohol if your health care provider tells you not to drink.
• If you drink alcohol, limit how much you have.
  • 0–1 drink a day for women.
  • 0–2 drinks a day for men.

General instructions

• Monitor your symptoms, and ask people around you to do the same. Recovery from brain injuries varies widely. Talk with your health care provider about what to expect.
• Take over-the-counter and prescription medicines only as told by your health care provider. Do not take blood thinners or NSAIDs unless your health care provider approves. These include aspirin, ibuprofen, naproxen, and warfarin.
• Keep all follow-up visits as told by your health care provider. This is important.

Where to find more information

• National Institute of Neurological Disorders and Stroke: www.ninds.nih.gov  
• American Academy of Neurology (AAN): www.aan.com  
• Brain Injury Association of America: www.biausa.org  

Get help right away if you:

• Are taking blood thinners and you fall or you experience minor trauma to the head. If you take any blood thinners, even a very small injury can cause a subdural hematoma.
• Have a bleeding disorder and you fall or you experience minor trauma to the head.
• Develop any of the following symptoms after a head injury:
  • Clear fluid draining from your nose or ears.
  • Nausea or vomiting.
  • Changes in speech or trouble understanding what people say.
  • Seizures.
  • Drowsiness or a decrease in alertness.
  • Double vision.
  • Numbness or inability to move (paralysis) in any part of your body.
  • Difficulty walking or poor coordination.
  • Difficulty thinking.
  • Confusion or forgetfulness.
  • Personality changes.
  • Irrational or aggressive behavior.

These symptoms may represent a serious problem that is an emergency. Do not wait to see if the symptoms will go away. Get medical help right away. Call your local emergency services (911 in the U.S.). Do not drive yourself to the hospital.

Summary

• A subdural hematoma is a collection of blood between the brain and its outer covering (dura).
• Treatment for this condition depends on what type of subdural hematoma you have and how severe it is.
• Symptoms can vary from mild to severe to life-threatening.
• Monitor your symptoms, and ask others around you to do the same.

Subdural Hematoma Evacuation

Subdural hematoma evacuation is a procedure to remove the collection of blood. A subdural hematoma is a collection of blood between the brain and its tough outer covering (dura). A subdural hematoma is caused by bleeding (hemorrhage) from a broken (ruptured) blood vessel. Bleeding results in blood clots that put pressure on the brain, which can be life-threatening.

Subdural hematoma evacuation may be done:

• To treat bleeding that develops slowly, over weeks or months (chronic subdural hematoma). The procedure may be needed if the bleeding becomes dangerous or it presses on the brain.
• As an emergency procedure to treat bleeding caused by a head injury (acute subdural hematoma).

During the procedure, the skull is opened and blood is gently flushed away using a germ-free salt-water (sterile saline) solution.

Tell a health care provider about:

• Any allergies you have.
• All medicines you are taking, including blood thinners, vitamins, herbs, eye drops, creams, and over-the-counter medicines.
• Any problems you or family members have had with anesthetic medicines.
• Any blood disorders you have, including a history of blood clots (thrombophlebitis).
• Any surgeries you have had.
• Any medical conditions you have.
• Whether you are pregnant or may be pregnant.

What are the risks?

Generally, this is a safe procedure. However, problems may occur, including:

• Infection, such as meningitis.
• Bleeding.
• Allergic reaction to medicines.
• Damage to other structures or organs.
• Headaches.
• Leakage of fluid that surrounds and protects the brain and spinal cord (cerebrospinal fluid).
• Jerky movements that you cannot control (seizure).
• Brain swelling.
• Stroke.

What happens before the procedure?

Staying hydrated

Follow instructions from your health care provider about hydration, which may include:

• Up to 2 hours before the procedure – you may continue to drink clear liquids, such as water, clear fruit juice, black coffee, and plain tea.

Eating and drinking restrictions

Follow instructions from your health care provider about eating and drinking, which may include:

• 8 hours before the procedure – stop eating heavy meals or foods such as meat, fried foods, or fatty foods.
• 6 hours before the procedure – stop eating light meals or foods, such as toast or cereal.
• 6 hours before the procedure – stop drinking milk or drinks that contain milk.
• 2 hours before the procedure – stop drinking clear liquids.

Medicines

• Ask your health care provider about:
  • Changing or stopping your regular medicines. This is especially important if you are taking diabetes medicines or blood thinners.
  • Taking medicines such as aspirin and ibuprofen. These medicines can thin your blood. Do not take these medicines before your procedure if your health care provider instructs you not to.
• You may be given antibiotic medicine to help prevent infection.

General instructions

• Ask your health care provider how your surgical site will be marked or identified.
• You may be asked to shower with a germ-killing soap.
• You may have an exam or testing.
• You may have a blood or urine sample taken.
• Plan to have someone take you home from the hospital or clinic.

What happens during the procedure?

• To reduce your risk of infection, your health care team will wash or sanitize their hands.
• An IV tube will be inserted into one of your veins.
• You will be given a medicine to make you fall asleep (general anesthetic). You may also be given medicine to help you relax (sedative).
• A germ-killing (antiseptic) solution will be used to wash the area where your skull will be opened. Hair will be removed from this area.
• Incisions will be made in your scalp.
• Small holes (burr holes) will be drilled into your skull. Then, a bone saw will be used to connect the burr holes until the section of your skull (bone flap) can be removed.
• After the bone flap is removed, the dura will be opened.
• Excess blood and any blood clots will be removed from your brain using a sterile saline solution or other solutions.
• A small tube (drain) may be placed inside your skull to remove blood and other fluids that can collect after surgery.
• The bone flap may be placed back in its original position.
  • If you have too much brain swelling, the bone flap will be saved in a storage area (bone bank), or a pocket will be created on your abdomen and the bone will be placed there. These methods are more likely to be needed if your hematoma happened suddenly.
  • If the bone flap is not replaced during your procedure, it will be replaced later, during another surgery. This will happen when your surgeon determines that your brain swelling has decreased enough to make replacement of the bone flap safe.
• The incisions in your scalp will be closed with stitches (sutures) or staples. Your head may be wrapped in bandages (dressings).

The procedure may vary among health care providers and hospitals.

What to expect after the procedure

• Your blood pressure, heart rate, breathing rate, and blood oxygen level will be monitored until the medicines you were given have worn off. You will continue to be monitored closely as you recover.
• Do not drive until your health care provider approves.
• You may continue to receive fluid and medicines through an IV tube.
• You will have some pain. You will be given medicine to relieve pain as needed.

Subdural Hematoma Evacuation, Care After

This sheet gives you information about how to care for yourself after your procedure. Your health care provider may also give you more specific instructions. If you have problems or questions, contact your health care provider.

What can I expect after the procedure?

After the procedure, it is common to have:

• Pain in your scalp, especially in the incision area. You will be given pain medicines to control this.
• Constipation.
• Headaches.

Follow these instructions at home:

Incision care

• Follow instructions from your health care provider about how to take care of your incision. Make sure you:
  • Wash your hands with soap and water before you change your bandage (dressing). If soap and water are not available, use hand sanitizer.
  • Change your dressing as told by your health care provider.
  • Leave stitches (sutures), skin glue, or adhesive strips in place. These skin closures may need to stay in place for 2 weeks or longer. If adhesive strip edges start to loosen and curl up, you may trim the loose edges. Do not remove adhesive strips completely unless your health care provider tells you to do that.
• Check your incision area every day for signs of infection. Check for:
  • More redness, swelling, or pain.
  • More fluid or blood.
  • Warmth.
  • Pus or a bad smell.

Medicines

• Take over-the-counter and prescription medicines only as told by your health care provider. Do not take blood thinners or NSAIDs unless your health care provider approves. These include aspirin, ibuprofen, naproxen, and warfarin.
• If you were prescribed an antibiotic medicine, use it as told by your health care provider. Do not stop using the antibiotic even if you start to feel better.

Activity

• Avoid any situation where there is potential for another head injury, such as football, hockey, soccer, basketball, martial arts, downhill snow sports, and horseback riding. Do not do these activities until your health care provider approves.
  • If you play a contact sport and you experience a head injury, follow advice from your health care provider about when you can return to the sport. If you get another injury while you are healing, you may experience another hemorrhage.
• Avoid excessive visual stimulation while recovering. This includes working on the computer, watching TV, and reading.
• Try to avoid activities that cause physical or mental stress. Stay home from work or school as directed by your health care provider.
• Do not drive, ride a bicycle, or use heavy machinery until your health care provider approves.
• Do not lift anything that is heavier than 5 lb (2.3 kg) until your health care provider approves.
• If physical therapy was prescribed, do exercises as told by your health care provider or physical therapist.
• Rest as told by your health care provider. Rest helps the brain to heal. Make sure you:
  • Get plenty of sleep. Avoid staying up late at night.
  • Keep a consistent sleep schedule. Try to go to sleep and wake up at about the same time every day.
  • Avoid activities that cause physical or mental stress.

General instructions

• To prevent or treat constipation while you are taking prescription pain medicine, your health care provider may recommend that you:
  • Drink enough fluid to keep your urine clear or pale yellow.
  • Take over-the-counter or prescription medicines.
  • Eat foods that are high in fiber, such as fresh fruits and vegetables, whole grains, and beans.
  • Limit foods that are high in fat and processed sugars, such as fried and sweet foods.
• Do not take baths, swim, or use a hot tub until your health care provider approves. You may take showers as directed by your health care provider.
• Limit alcohol intake to no more than 1 drink per day for nonpregnant women and 2 drinks per day for men. One drink equals 12 oz of beer, 5 oz of wine, or 1½ oz of hard liquor.
• Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

• You have a fever.
• You have pain that does not get better with medicine.
• You have no appetite.
• You have constipation that does not get better with stool softeners.
• You have more redness, swelling, or pain around your incision.
• You have more fluid or blood coming from your incision.
• Your incision feels warm to the touch.
• You have pus or a bad smell coming from your incision.

Get help right away if:

• Your incision opens.
• You have severe headaches.
• You develop confusion.
• You have jerky movements that you cannot control (seizure).
• You develop weakness or numbness on one side of your body.
• You have nausea or vomiting.
• You have vision problems.
• You have chest pain.
• You have trouble breathing.
• You have pain or swelling in your calves.