Sub dural hemotoma - Clinicals, Diagnosis, and Management

Neurosurgery

Clinicals - History

Fact Explanation
Introduction Accumulation of blood in between dura and arachnoid causing haematoma from bridging vessels on the surface of the brain. This can be divide into acute and chronic.
Acute Sub dural hemotomas are sudden onset of haematoma usually following a severe trauma. Usually this is associated with underlying brain damage and marked reduction of cerebral blood flow. Prognosis will not good with this type.
Chronic Sub dural hemotomas occur few days to weeks after a trauma. Majority will be asymptomatic (as small haemorrhages will absorb) and this is associated with atrophy of the brain matter. This is common among males, elderly patients and alcoholic patients.
Introduction
Accumulation of blood in between dura and arachnoid causing haematoma from bridging vessels on the surface of the brain. This can be divide into acute and chronic.
Acute Sub dural hemotomas are sudden onset of haematoma usually following a severe trauma. Usually this is associated with underlying brain damage and marked reduction of cerebral blood flow. Prognosis will not good with this type.
Chronic Sub dural hemotomas occur few days to weeks after a trauma. Majority will be asymptomatic (as small haemorrhages will absorb) and this is associated with atrophy of the brain matter. This is common among males, elderly patients and alcoholic patients.
History of impaired consciousness and abnormal behavior patient will have fluctuating level of consciousness, insidious physical or interlectual slowing, sleepiness, personality changes and unsteadiness. All of these symptoms are due to the cerebral involvement following Sub dural hemotoma. Irritation by leaked blood, vasospasm with bleeding causing ischemia, cerebral oedema and increased intracranial pressure can leds to these symptoms. History of impaired consciousness and abnormal behavior
patient will have fluctuating level of consciousness, insidious physical or interlectual slowing, sleepiness, personality changes and unsteadiness. All of these symptoms are due to the cerebral involvement following Sub dural hemotoma. Irritation by leaked blood, vasospasm with bleeding causing ischemia, cerebral oedema and increased intracranial pressure can leds to these symptoms.
Headache Patient will develop sudden on set headache. The headache is usually associated with nausea and vomiting . the headache can be exacerbate with coughtin and straining like situations which increases the pressure in side the body. Headache
Patient will develop sudden on set headache. The headache is usually associated with nausea and vomiting . the headache can be exacerbate with coughtin and straining like situations which increases the pressure in side the body.
Development of seizures With the head injury or secondary to sub dural haematoma can cause brain damage causing neuronal damage. So this can be associated with abnormal neuronal transmission of the impulses causing seizures. Development of seizures
With the head injury or secondary to sub dural haematoma can cause brain damage causing neuronal damage. So this can be associated with abnormal neuronal transmission of the impulses causing seizures.
History of head trauma Trauma to head will give an aetiology for the condition. Sudden severe head trauma can cause huge acute sub dural haematoma and repeated head injuries( eg: in gender based violence, in child abuse) will leads to chronic sub dural haematoma. History of head trauma
Trauma to head will give an aetiology for the condition. Sudden severe head trauma can cause huge acute sub dural haematoma and repeated head injuries( eg: in gender based violence, in child abuse) will leads to chronic sub dural haematoma.
History of alcohol misuse Long term alcohol misuse leads to brain arophy and causes stretching of the blood vessels over the surface of the brain. This facilitate the bridging of vessels. Also patients can face several head injuries under the influence of alcohol. History of alcohol misuse
Long term alcohol misuse leads to brain arophy and causes stretching of the blood vessels over the surface of the brain. This facilitate the bridging of vessels. Also patients can face several head injuries under the influence of alcohol.
Drug history of anticoagulants/ anti platelets Drugs like waferin, enoxaparin, aspirin and increases the bleeding tendency. Drug history of anticoagulants/ anti platelets
Drugs like waferin, enoxaparin, aspirin and increases the bleeding tendency.
Past history of hypertension/ dyslipidaemia. These factors are acquired risk factors for weakening the blood vessels and development of Sub dural hemotoma. Past history of hypertension/ dyslipidaemia.
These factors are acquired risk factors for weakening the blood vessels and development of Sub dural hemotoma.
Past history of aneurysm/ arteriovenous malformations Spontaneous subdural hematoma can be associated with aneurysms/arteriovenous malformations. Following the rupture of the aneurysms or bleeding from arteriovenous malformations, blood can pass throught the parenchyma of the brain/subarachnoid space causing subdural hematoma. Past history of aneurysm/ arteriovenous malformations
Spontaneous subdural hematoma can be associated with aneurysms/arteriovenous malformations. Following the rupture of the aneurysms or bleeding from arteriovenous malformations, blood can pass throught the parenchyma of the brain/subarachnoid space causing subdural hematoma.
past hitory of primary tumour in brain/ evidence of metastases to the brain Primary/ secondary tumors of the brain can give symptoms of space occupying lesion. Also tumours can bleed and cause subdural hematomas. past hitory of primary tumour in brain/ evidence of metastases to the brain
Primary/ secondary tumors of the brain can give symptoms of space occupying lesion. Also tumours can bleed and cause subdural hematomas.
Recent history of head surgery Post surgical bleeding can cause sub dural haematomas. Recent history of head surgery
Post surgical bleeding can cause sub dural haematomas.
History of being abused Being a victim for an abuse (eg: Shaken baby syndrome) or violence will cause repeated injuries. This can lead to chronic sub dural haematomas. History of being abused
Being a victim for an abuse (eg: Shaken baby syndrome) or violence will cause repeated injuries. This can lead to chronic sub dural haematomas.
Past history of epilepsy In epilepsy patient is at high risk of fall and getting injuries. Past history of epilepsy
In epilepsy patient is at high risk of fall and getting injuries.
Recent history of lumbar puncture/ spinal anesthesia or insertion of a lumboperitoneal shunt Following these conditions there will be intracranial hypotension which can ultimately leads to the development of sub dural haematoma. The exact mechanism is not clear but it is thought to be bridging vessels on the surface of the brain following down ward displacement of the brain with intracranial hypotension . Recent history of lumbar puncture/ spinal anesthesia or insertion of a lumboperitoneal shunt
Following these conditions there will be intracranial hypotension which can ultimately leads to the development of sub dural haematoma. The exact mechanism is not clear but it is thought to be bridging vessels on the surface of the brain following down ward displacement of the brain with intracranial hypotension .

Clinicals - Examination

Fact Explanation
General examination In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma with Glasgow Coma Score.
.
General examination
In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma with Glasgow Coma Score.
.
Signs suggestive of increased intra cranial pressure Patient will have nausea, vomiting with neurological symptoms. on fundoscopic examination there will be papilledema. Signs suggestive of increased intra cranial pressure
Patient will have nausea, vomiting with neurological symptoms. on fundoscopic examination there will be papilledema.
Neurological examination Neurologic examination reveals alteration in mental status (confusion/ drowsiness), development of seizures, hemiplegia, paresthesias, visual disturbance. Recent asymmetrical findings in neurological examination will suggest cerebral patology. Neurological examination
Neurologic examination reveals alteration in mental status (confusion/ drowsiness), development of seizures, hemiplegia, paresthesias, visual disturbance. Recent asymmetrical findings in neurological examination will suggest cerebral patology.
Evidence of blunt head trauma Can look for any wounds, bruises over the head, any signs of base of skull fracture ( like bilateral periorbital oedaema, Battle’s sign, cerebrospinal fluid rhinorrhoea or otorrhoea
Haemotympanum or bleeding from ear).
Evidence of blunt head trauma
Can look for any wounds, bruises over the head, any signs of base of skull fracture ( like bilateral periorbital oedaema, Battle’s sign, cerebrospinal fluid rhinorrhoea or otorrhoea
Haemotympanum or bleeding from ear).
Evidence of increased bleeding tendency multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding). Evidence of increased bleeding tendency
multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding).
Examination of the back To assess any evidence (Eg: scars/ plasters over the lower lumbar area) of recently done lumbar puncture/ saddle block. Examination of the back
To assess any evidence (Eg: scars/ plasters over the lower lumbar area) of recently done lumbar puncture/ saddle block.

Investigations - Diagnosis

Fact Explanation
CT scan This will show the typical crescent shape collection of blood. If the haematoma is large there will be associated midline shift towards the normal side. The density of the haematoma will give an idea about the duration of the duration of it (eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense)

Acoordin to NICE guidelines for computerised tomography (CT)
in head injury
-Glasgow Coma Score (GCS) < 13 at any point
-GCS 13 or 14 at 2 hours
-Focal neurological deficit
-Suspected open, depressed or basal skull fracture
-Seizure
-Vomiting > one episode

Urgent CT head scan if none of the above but:
- Age > 65
-Coagulopathy (e.g. on warfarin)
-Dangerous mechanism of injury (CT within 8 hours)
-Antegrade amnesia > 30 min (CT within 8 hours)
CT scan
This will show the typical crescent shape collection of blood. If the haematoma is large there will be associated midline shift towards the normal side. The density of the haematoma will give an idea about the duration of the duration of it (eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense)

Acoordin to NICE guidelines for computerised tomography (CT)
in head injury
-Glasgow Coma Score (GCS) < 13 at any point
-GCS 13 or 14 at 2 hours
-Focal neurological deficit
-Suspected open, depressed or basal skull fracture
-Seizure
-Vomiting > one episode

Urgent CT head scan if none of the above but:
- Age > 65
-Coagulopathy (e.g. on warfarin)
-Dangerous mechanism of injury (CT within 8 hours)
-Antegrade amnesia > 30 min (CT within 8 hours)
MRI scan This will be useful in assessing the underlying brain damage following trauma. MRI scan
This will be useful in assessing the underlying brain damage following trauma.

Investigations - Management

Fact Explanation
FBC During follow up this is useful to assess the associated anaemia condition and need of blood transfusion. Also can identify any associated infections. FBC
During follow up this is useful to assess the associated anaemia condition and need of blood transfusion. Also can identify any associated infections.
CT scanning This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus. CT scanning
This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus.
Serum electrolytes Electrolyte disturbances like hyponatraemia can cause drosiness, loss of consiousness and seizures. As this can be commonly occur in elderly patients, excusion of those possibilities will be important. Serum electrolytes
Electrolyte disturbances like hyponatraemia can cause drosiness, loss of consiousness and seizures. As this can be commonly occur in elderly patients, excusion of those possibilities will be important.
EEG This will be useful in monitoring the patients brain function and also will useful during the management (eg if patient is giving barbiturates to reduce intracranial pressure the dose need to be guided by EEG monitoring as it is associated with respiratory and metabolic
complications).
EEG
This will be useful in monitoring the patients brain function and also will useful during the management (eg if patient is giving barbiturates to reduce intracranial pressure the dose need to be guided by EEG monitoring as it is associated with respiratory and metabolic
complications).
FBC This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries. FBC
This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries.
Clotting profile with PT/ INR, APTT These test also useful to assess the clotting status of the patient. Clotting profile with PT/ INR, APTT
These test also useful to assess the clotting status of the patient.
Renal function tests like serum electrolylres, serum creatinine, blood urea Assessment of the renal function of the patient is useful during imaging and pre operatively to assess the fitness for surgery. Renal function tests like serum electrolylres, serum creatinine, blood urea
Assessment of the renal function of the patient is useful during imaging and pre operatively to assess the fitness for surgery.
ECG These will be helpful in pre-operative fitness assessment specially in elderly poppulation. ECG
These will be helpful in pre-operative fitness assessment specially in elderly poppulation.
Chest X ray This will give an idea about lung status and this use before surgical procedures to assess the fitness. Chest X ray
This will give an idea about lung status and this use before surgical procedures to assess the fitness.
Blood grouping and cross matching This need to be done pre operatively and blood should be preserved. Blood grouping and cross matching
This need to be done pre operatively and blood should be preserved.
Clotting profile with PT /INR, APTT As Sub dural hemotoma can be associated with bleeding problems, Clotting profile will useful in screening for any associated clotting defect. Clotting profile with PT /INR, APTT
As Sub dural hemotoma can be associated with bleeding problems, Clotting profile will useful in screening for any associated clotting defect.
CT scan As there will be changes indensity of the haematoma with the time(eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense), this can be use to stage the Sub dural hemotoma either as acute or chronic. CT scan
As there will be changes indensity of the haematoma with the time(eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense), this can be use to stage the Sub dural hemotoma either as acute or chronic.

Management - Supportive

Fact Explanation
Resuscitation and stabilization of the patient According to the patients condition, especially in an acute sub dural haematoma, initial steps need stabilization of the patient including ABC management. Airway of the patient should be secured. Airway secretions during seizures, defective swallowing ability can lead to airway obstruction. Secretions should be sucked out and can be temporally maintained with an oral airway, when there is persistent obstruction and high risk of aspiration immediate intubation with endotracheal tube is beneficial. Breathing of the patient can be affected by increased intracranial pressure causing respiratory center suprresion. In these kind of instances immediate intubation with ventilatory support should be given in an ICU setup. Even though the blood pressure would be elevated during initial phase circulatory collapse could occur due to carciac center inhibition due to increased intracranial pressure, so adequate fluid resuscitation with inotrop support may be needed. When the patients are having seizures it should be actively managed and prevented because it could further impede the cerebral perfusion. Resuscitation and stabilization of the patient
According to the patients condition, especially in an acute sub dural haematoma, initial steps need stabilization of the patient including ABC management. Airway of the patient should be secured. Airway secretions during seizures, defective swallowing ability can lead to airway obstruction. Secretions should be sucked out and can be temporally maintained with an oral airway, when there is persistent obstruction and high risk of aspiration immediate intubation with endotracheal tube is beneficial. Breathing of the patient can be affected by increased intracranial pressure causing respiratory center suprresion. In these kind of instances immediate intubation with ventilatory support should be given in an ICU setup. Even though the blood pressure would be elevated during initial phase circulatory collapse could occur due to carciac center inhibition due to increased intracranial pressure, so adequate fluid resuscitation with inotrop support may be needed. When the patients are having seizures it should be actively managed and prevented because it could further impede the cerebral perfusion.
Close monitoring Close monitoring of the patient's general condition, blood pressure, pulse rate, respiratory rate, pupillary reaction, Glasgow coma scale need to be done. Close monitoring
Close monitoring of the patient's general condition, blood pressure, pulse rate, respiratory rate, pupillary reaction, Glasgow coma scale need to be done.
Medical management of raised intracranial pressure In medical management of raised intracranial pressure,

Position of the patient need to be done with head up 30º this will avoid obstruction of venous drainage from head.

Sedation of the patient can be done either wit or with out muscle relaxant. This will calm down the patient.

Patient should be ventilated and will need to incubate according to patients condition to maintain normocapnia 4.5–5.0 kPa.

Diuretics such as furosemide, mannitol will reduce raised intracranial pressure temporarily by reducing cerebral swelling.

If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed. This is important as seizures will increase the brain metabolic rate.

If patient is having fever, anti pyratics can be given such as paracetamol. As hperthermia will increase the brain metabolic rate, maintaining normothermia is important.

Fluid and electrolyte balance need to be maintaining with close monitoring as in severely brain-injured patients are susceptible to disturbances of sodium haemostasis (eg:diabetes insipidus and syndrome of inappropriate
antidiuretic hormone).
Medical management of raised intracranial pressure
In medical management of raised intracranial pressure,

Position of the patient need to be done with head up 30º this will avoid obstruction of venous drainage from head.

Sedation of the patient can be done either wit or with out muscle relaxant. This will calm down the patient.

Patient should be ventilated and will need to incubate according to patients condition to maintain normocapnia 4.5–5.0 kPa.

Diuretics such as furosemide, mannitol will reduce raised intracranial pressure temporarily by reducing cerebral swelling.

If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed. This is important as seizures will increase the brain metabolic rate.

If patient is having fever, anti pyratics can be given such as paracetamol. As hperthermia will increase the brain metabolic rate, maintaining normothermia is important.

Fluid and electrolyte balance need to be maintaining with close monitoring as in severely brain-injured patients are susceptible to disturbances of sodium haemostasis (eg:diabetes insipidus and syndrome of inappropriate
antidiuretic hormone).
Control hypertension If patient is having hypertension, adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure. Control hypertension
If patient is having hypertension, adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure.
If the patient is comatose Intubated and mechanically ventilation will be needed. Nutrition supplymentation and hydration can be done via nasogastric tubes or via parenteral rout. If the patient is comatose
Intubated and mechanically ventilation will be needed. Nutrition supplymentation and hydration can be done via nasogastric tubes or via parenteral rout.
Catheretization This will be important in assessing the urine out put in both pre oparative (to minimize further falls) and post operative periods. Catheretization
This will be important in assessing the urine out put in both pre oparative (to minimize further falls) and post operative periods.
Prevent Deep vein thrombosis During pre operative period and post operatively Prevention of deep vein thrombosis is very important. Compression stockings, intermittent pneumatic compression of the calves will be useful in here. Prevent Deep vein thrombosis
During pre operative period and post operatively Prevention of deep vein thrombosis is very important. Compression stockings, intermittent pneumatic compression of the calves will be useful in here.
Anti emetics Anti emetics like promethazine will be useful in the presence of recurrent vomiting. Anti emetics
Anti emetics like promethazine will be useful in the presence of recurrent vomiting.
Patient education The patient and the family members should be thoroughly educated regarding the condition, probable aetiology, complications associated with, investigation and treatment options available and prognosis. During the resuscitation phase in high risk patients (eg: acute severe Sub dural haematoma) the family should be emphasized regarding the illness and risk on life as well as the care of disabled patient following recovery. This should include the hydration, nutrition, prevention of DVT, prevention of bed sores and first aid care during seizures. Patient education
The patient and the family members should be thoroughly educated regarding the condition, probable aetiology, complications associated with, investigation and treatment options available and prognosis. During the resuscitation phase in high risk patients (eg: acute severe Sub dural haematoma) the family should be emphasized regarding the illness and risk on life as well as the care of disabled patient following recovery. This should include the hydration, nutrition, prevention of DVT, prevention of bed sores and first aid care during seizures.
Preventive measures First need to be identify the aetiological cause for the development of sub dural haematoma. ( eg: If the sub dural haematoma is secondary to head trauma, identify any associated vision problems, difficulty in walking, use of alcohol, high risk works like occupation, cognitive imparement) These conditions should be address and correct/ minimize as far as possible. Preventive measures
First need to be identify the aetiological cause for the development of sub dural haematoma. ( eg: If the sub dural haematoma is secondary to head trauma, identify any associated vision problems, difficulty in walking, use of alcohol, high risk works like occupation, cognitive imparement) These conditions should be address and correct/ minimize as far as possible.
Neurorehabilitation In considering the long-term management of the brain-injured patient, Neurorehabilitation will be use ful in improving the quality of life. For this the help of medical, nursing, physiotherapy and speech
and occupational therapy teams will be important.
Neurorehabilitation
In considering the long-term management of the brain-injured patient, Neurorehabilitation will be use ful in improving the quality of life. For this the help of medical, nursing, physiotherapy and speech
and occupational therapy teams will be important.

Management - Specific

Fact Explanation
Surgical intervention The surgical intervention for the SDH is dependent on the the type of SDH weather acute or chronic, timing, size of the haematoma, location and the patient's medical fitness for the surgery.

In acute SDH evacuation of the haematoma via craniotomy is indicated when the CT shows a haematoma more than 5 mm thickness and when the the patient shows a neurological impairment or focal weakness. If the above indications are there surgery would be carried out irrespective of the GCS level. Creniectomy is also n practice when the increased intracranial pressure is anticipated.

In chronic SDH evacuation is indicated when the patient is symptomatic, when there is a significant mass effect on CT or when the CT shows and expanding lesion with normal neurology. The surgery for chronic SDH is usually via bur hole aspiration. In some instances the craniotomy is also indicated.

Contra indications for surgery

No specific contra indications for the surgery but has to be applied in to the individual patient. When the patient is having massive haematoma with marked neurological deficit with poor out come usually the surgery will not be indicated. On the other hand acute SDH with less than 5 mm thickness without much neurological impairment and mass effect also will be monitored with tomography.
In chronic SDH also asymptomatic haematomas without much pressure effects will be monitored with out active intervention.
Surgical intervention
The surgical intervention for the SDH is dependent on the the type of SDH weather acute or chronic, timing, size of the haematoma, location and the patient's medical fitness for the surgery.

In acute SDH evacuation of the haematoma via craniotomy is indicated when the CT shows a haematoma more than 5 mm thickness and when the the patient shows a neurological impairment or focal weakness. If the above indications are there surgery would be carried out irrespective of the GCS level. Creniectomy is also n practice when the increased intracranial pressure is anticipated.

In chronic SDH evacuation is indicated when the patient is symptomatic, when there is a significant mass effect on CT or when the CT shows and expanding lesion with normal neurology. The surgery for chronic SDH is usually via bur hole aspiration. In some instances the craniotomy is also indicated.

Contra indications for surgery

No specific contra indications for the surgery but has to be applied in to the individual patient. When the patient is having massive haematoma with marked neurological deficit with poor out come usually the surgery will not be indicated. On the other hand acute SDH with less than 5 mm thickness without much neurological impairment and mass effect also will be monitored with tomography.
In chronic SDH also asymptomatic haematomas without much pressure effects will be monitored with out active intervention.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. ABDALLAH C. Considerations in perioperative assessment of valproic acid coagulopathy J Anaesthesiol Clin Pharmacol [online] 2014, 30(1):7-9 [viewed 25 October 2014] Available from: doi:10.4103/0970-9185.125685
  2. ADHIYAMAN V, ASGHAR M, GANESHRAM K, BHOWMICK B. Chronic subdural haematoma in the elderly Postgrad Med J [online] 2002 Feb, 78(916):71-75 [viewed 27 October 2014] Available from: doi:10.1136/pmj.78.916.71
  3. AKINS PT, AXELROD YK, JI C, CIPOREN JN, ARSHAD ST, HAWK MW, GUPPY KH. Cerebral venous sinus thrombosis complicated by subdural hematomas: Case series and literature review Surg Neurol Int [online] :85 [viewed 28 October 2014] Available from: doi:10.4103/2152-7806.113651
  4. ASHKENAZI E, POMERANZ S. Nystagmus as the presentation of tentorial incisure subdural haematoma. J Neurol Neurosurg Psychiatry [online] 1994 Jul, 57(7):830-831 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073024
  5. BHAT AR, KIRMANI AR, WANI MA. Decompressive craniectomy with multi-dural stabs - A combined (SKIMS) technique to evacuate acute subdural hematoma with underlying severe traumatic brain edema Asian J Neurosurg [online] 2013, 8(1):15-20 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.110275
  6. BLUMENTHAL I. Shaken baby syndrome Postgrad Med J [online] 2002 Dec, 78(926):732-735 [viewed 28 October 2014] Available from: doi:10.1136/pmj.78.926.732
  7. BRODEUR BR, BOYER M, CHARLEBOIS I, HAMEL J, COUTURE F, RIOUX CR, MARTIN D. Identification of Group B Streptococcal Sip Protein, Which Elicits Cross-Protective Immunity Infect Immun [online] 2000 Oct, 68(10):5610-5618 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101513
  8. CAMERON MM. Chronic subdural haematoma: a review of 114 cases. J Neurol Neurosurg Psychiatry [online] 1978 Sep, 41(9):834-839 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC493164
  9. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.116390
  10. CHUGH AP, GANDHOKE CS, MOHITE AG, KHEDKAR BV. Primary angiosarcoma of the skull: A rare case report Surg Neurol Int [online] :92 [viewed 25 October 2014] Available from: doi:10.4103/2152-7806.134365
  11. CINCU R, DE ASIS LORENTE F, RIVERO D, EIRAS J, ARA JR. Spontaneous subdural hematoma of the thoracolumbar region with massive recurrent bleed Indian J Orthop [online] 2009, 43(4):412-415 [viewed 25 October 2014] Available from: doi:10.4103/0019-5413.49383
  12. DE NORONHA RJ, SHARRACK B, HADJIVASSILIOU M, ROMANOWSKI C. Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension J Neurol Neurosurg Psychiatry [online] 2003 Jun, 74(6):752-755 [viewed 28 October 2014] Available from: doi:10.1136/jnnp.74.6.752
  13. FARRELL DJ, BOWER L. Fatal water intoxication J Clin Pathol [online] 2003 Oct, 56(10):803-804 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770067
  14. FRAZIER CH. THE SURGICAL MANAGEMENT OF CHRONIC SUBDURAL HEMATOMA Ann Surg [online] 1935 Feb, 101(2):671-689 [viewed 29 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1392044
  15. FREEMAN WK, GIBBONS RJ. Perioperative Cardiovascular Assessment of Patients Undergoing Noncardiac Surgery Mayo Clin Proc [online] 2009 Jan, 84(1):79-90 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664575
  16. GABAEFF SC. Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome West J Emerg Med [online] 2011 May, 12(2):144-158 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099599
  17. GODLEWSKI B, ZAPALOWICZ K. Atypical presentations of chronic subdural hematomas J Neurosci Rural Pract [online] 2014, 5(4):328-329 [viewed 28 October 2014] Available from: doi:10.4103/0976-3147.139963
  18. GUTHKELCH AN. Infantile Subdural Haematoma and its Relationship to Whiplash Injuries Br Med J [online] 1971 May 22, 2(5759):430-431 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1796151
  19. HADDAD SH, ARABI YM. Critical care management of severe traumatic brain injury in adults Scand J Trauma Resusc Emerg Med [online] :12 [viewed 25 October 2014] Available from: doi:10.1186/1757-7241-20-12
  20. HARRISON C, KHAIR K, BAXTER B, RUSSELL-EGGITT I, HANN I, LIESNER R. Hermansky-Pudlak syndrome: infrequent bleeding and first report of Turkish and Pakistani kindreds Arch Dis Child [online] 2002 Apr, 86(4):297-301 [viewed 27 October 2014] Available from: doi:10.1136/adc.86.4.297
  21. HASSEN GW, KALANTARI H. Diplopia from Subacute Bilateral Subdural Hematoma after Spinal Anesthesia West J Emerg Med [online] 2012 Feb, 13(1):108-110 [viewed 29 October 2014] Available from: doi:10.5811/westjem.2011.8.6872
  22. HOU K, LI CG, ZHANG Y, ZHU BX. The Surgical Treatment of Three Young Chronic Subdural Hematoma Patients with Different Causes J Korean Neurosurg Soc [online] 2014 Apr, 55(4):218-221 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2014.55.4.218
  23. JAGATSINH Y. Cauda equina syndrome: A rare complication in intensive care Indian J Orthop [online] 2009, 43(3):309-311 [viewed 27 October 2014] Available from: doi:10.4103/0019-5413.50873
  24. JAYAWANT S, PARR J. Outcome following subdural haemorrhages in infancy Arch Dis Child [online] 2007 Apr, 92(4):343-347 [viewed 25 October 2014] Available from: doi:10.1136/adc.2005.084988
  25. JONES SC, BAMFORD JM, HEATH J, BRADEY N, HEATLEY RV. Multiple forms of epileptic attack secondary to a small chronic subdural haematoma. BMJ [online] 1989 Aug 12, 299(6696):439-441 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1837297
  26. KIM BW, JUNG YJ, KIM MS, CHOI BY. Chronic Subdural Hematoma after Spontaneous Intracranial Hypotension : A Case Treated with Epidural Blood Patch on C1-2 J Korean Neurosurg Soc [online] 2011 Sep, 50(3):274-276 [viewed 29 October 2014] Available from: doi:10.3340/jkns.2011.50.3.274
  27. KIM HJ, CHO YJ, CHO JY, LEE DH, HONG KS. Acute Subdural Hematoma Following Spinal Cerebrospinal Fluid Drainage in a Patient with Freezing of Gait J Clin Neurol [online] 2009 Jun, 5(2):95-96 [viewed 29 October 2014] Available from: doi:10.3988/jcn.2009.5.2.95
  28. KOLLATOS C, KONSTANTINOU D, RAFTOPOULOS S, KLIRONOMOS G, MESSINIS L, ZAMPAKIS P, PAPATHANASOPOULOS P, PANAGIOTOPOULOS V. Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma Hippokratia [online] 2011, 15(4):370-372 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876859
  29. KRISHNAN P, KARTIKUEYAN R. Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature J Pediatr Neurosci [online] 2013, 8(2):177-179 [viewed 28 October 2014] Available from: doi:10.4103/1817-1745.117869
  30. LEE BR, LEE JR, KIM MS. Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report Korean J Anesthesiol [online] 2014 Feb, 66(2):160-163 [viewed 25 October 2014] Available from: doi:10.4097/kjae.2014.66.2.160
  31. LEE KS, SHIM JJ, YOON SM, DOH JW, YUN IG, BAE HG. Acute-on-Chronic Subdural Hematoma: Not Uncommon Events J Korean Neurosurg Soc [online] 2011 Dec, 50(6):512-516 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2011.50.6.512
  32. LEWIN W. Acute Subdural and Extradural Haematoma in Closed Head Injuries: Hunterian lecture delivered at the Royal College of Surgeons of England on 23rd February, 1949 Ann R Coll Surg Engl [online] 1949 Oct, 5(4):240-274 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2238383
  33. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441
  34. LOUIS L, BAIR N, BANJAC S, DWEIK RA, TONELLI AR. Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs Pulm Circ [online] 2012, 2(4):518-521 [viewed 28 October 2014] Available from: doi:10.4103/2045-8932.105041
  35. MADHUGIRI VS, ARIMAPPAMAGAN A, CHANDRAMOULI BA. Traumatic epidural and subdural hematomas and extensive brain infarcts in a patient with pial arteriovenous malformation: Mechanisms underlying clinical and radiological findings Asian J Neurosurg [online] 2012, 7(4):210-213 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.106657
  36. MAK CH, LU YY, WONG GK. Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage Vasc Health Risk Manag [online] 2013:353-359 [viewed 25 October 2014] Available from: doi:10.2147/VHRM.S34046
  37. MCKENZIE KG. A SURGICAL AND CLINICAL STUDY OF NINE CASES OF CHRONIC SUB-DURAL HAEMATOMA Can Med Assoc J [online] 1932 May, 26(5):534-544 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC402332
  38. MEGUINS LC, SAMPAIO GB, ABIB EC, ADRY RA, ELLAKKIS RF, RIBEIRO FW, MASET ÂL, DE MORAIS DF. Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): a case report J Med Case Rep [online] :153 [viewed 25 October 2014] Available from: doi:10.1186/1752-1947-8-153
  39. MERKLER AE, SAINI V, KAMEL H, STIEG PE. Preoperative Steroid Use and the Risk of Infectious Complications After Neurosurgery Neurohospitalist [online] 2014 Apr, 4(2):80-85 [viewed 25 October 2014] Available from: doi:10.1177/1941874413510920
  40. MISHRA A, OJHA BK, CHANDRA A, SRIVASTAVA C, SINGH SK. Giant unusual shaped chronic subdural hematoma in a patient with untreated congenital hydrocephalus Asian J Neurosurg [online] 2011, 6(2):121-122 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.92183
  41. MONTAIN SJ, CHEUVRONT SN, SAWKA MN. Exercise associated hyponatraemia: quantitative analysis to understand the aetiology Br J Sports Med [online] 2006 Feb, 40(2):98-105 [viewed 25 October 2014] Available from: doi:10.1136/bjsm.2005.018481
  42. MOON W, JOO W, CHOUGH J, PARK H. Spontaneous Spinal Subdural Hematoma Concurrent with Cranial Subdural Hematoma J Korean Neurosurg Soc [online] 2013 Jul, 54(1):68-70 [viewed 28 October 2014] Available from: doi:10.3340/jkns.2013.54.1.68
  43. MULLIGAN P, RAORE B, LIU S, OLSON JJ. Neurological and functional outcomes of subdural hematoma evacuation in patients over 70 years of age J Neurosci Rural Pract [online] 2013, 4(3):250-256 [viewed 25 October 2014] Available from: doi:10.4103/0976-3147.118760
  44. NORDSTRöM A, NORDSTRöM P. Cognitive Performance in Late Adolescence and the Subsequent Risk of Subdural Hematoma: An Observational Study of a Prospective Nationwide Cohort PLoS Med [online] 2011 Dec, 8(12):e1001151 [viewed 28 October 2014] Available from: doi:10.1371/journal.pmed.1001151
  45. OHNO K, MAEHARA T, ICHIMURA K, SUZUKI R, HIRAKAWA K, MONMA S. Low incidence of seizures in patients with chronic subdural haematoma. J Neurol Neurosurg Psychiatry [online] 1993 Nov, 56(11):1231-1233 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC489829
  46. PAN A, ROGERS AG, HILL NC, HENTELEFF PD. Bilateral Subdural Hematoma Complicating Phenylindanedione (Danilone) Therapy Can Med Assoc J [online] 1962 Nov 24, 87(21):1119-1120 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1849828
  47. PARK HR, LEE KS, SHIM JJ, YOON SM, BAE HG, DOH JW. Multiple Densities of the Chronic Subdural Hematoma in CT Scans J Korean Neurosurg Soc [online] 2013 Jul, 54(1):38-41 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2013.54.1.38
  48. PARK IB, MOON SY, KIM YY, KWON YE, LEE JH. Acute-on-chronic subdural hematoma by spinal anesthesia in a patient with undiagnosed chronic subdural hematoma -A case report- Korean J Anesthesiol [online] 2011 Jul, 61(1):75-78 [viewed 25 October 2014] Available from: doi:10.4097/kjae.2011.61.1.75
  49. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 29 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  50. RYAN CG, THOMPSON RE, TEMKIN NR, CRANE PK, ELLENBOGEN RG, ELMORE JG. Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center J Trauma Acute Care Surg [online] 2012 Nov, 73(5):1348-1354 [viewed 25 October 2014] Available from: doi:10.1097/TA.0b013e31826fcb30
  51. SCHWEIGER V, ZANCONATO G, LONATI G, BAGGIO S, GOTTIN L, POLATI E. Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section Case Rep Obstet Gynecol [online] 2013:253408 [viewed 25 October 2014] Available from: doi:10.1155/2013/253408
  52. TISDALL M, CROCKER M, WATKISS J, SMITH M. Disturbances of sodium in critically ill adult neurologic patients: a clinical review J Neurosurg Anesthesiol [online] 2006 Jan, 18(1):57-63 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513666
  53. TSENG JH, TSENG MY, LIU AJ, LIN WH, HU HY, HSIAO SH. Risk Factors for Chronic Subdural Hematoma after a Minor Head Injury in the Elderly: A Population-Based Study Biomed Res Int [online] 2014:218646 [viewed 25 October 2014] Available from: doi:10.1155/2014/218646
  54. UPADHYAY P, TRIPATHI VN, SINGH RP, SACHAN D. Role of hypertonic saline and mannitol in the management of raised intracranial pressure in children: A randomized comparative study J Pediatr Neurosci [online] 2010, 5(1):18-21 [viewed 25 October 2014] Available from: doi:10.4103/1817-1745.66673
  55. UTKU U, GüLER S, YALNıZ E, ÜNLü E. Subdural and Cerebellar Hematomas Which Developed after Spinal Surgery: A Case Report and Review of the Literature Case Rep Neurol Med [online] 2013:431261 [viewed 28 October 2014] Available from: doi:10.1155/2013/431261
  56. VAN GOMPEL JJ, STEAD SM, GIANNINI C, MEYER FB, MARSH WR, FOUNTAIN T, SO E, COHEN-GADOL A, LEE KH, WORRELL GA. Phase I trial: safety and feasibility of intracranial electroencephalography using hybrid subdural electrodes containing macro- and microelectrode arrays Neurosurg Focus [online] 2008 Sep, 25(3):E23 [viewed 25 October 2014] Available from: doi:10.3171/FOC/2008/25/9/E23
  57. VLADISLAV P, BERNARD G, CHIBBARO S. Chronic subdural haematoma management: an iatrogenic complication. Case report and literature review BMJ Case Rep [online] :bcr1220115397 [viewed 25 October 2014] Available from: doi:10.1136/bcr.12.2011.5397
  58. WALL M. Idiopathic Intracranial Hypertension Neurol Clin [online] 2010 Aug, 28(3):593-617 [viewed 25 October 2014] Available from: doi:10.1016/j.ncl.2010.03.003
  59. WANG HS, KIM SW, KIM SH. Spontaneous Chronic Subdural Hematoma in an Adolescent Girl J Korean Neurosurg Soc [online] 2013 Mar, 53(3):201-203 [viewed 28 October 2014] Available from: doi:10.3340/jkns.2013.53.3.201
  60. YAMADA Y, INAMASU J, MORIYA S, OGURI D, HASEGAWA M, ABE M, HIROSE Y. Subdural Hematoma Caused by Epithelioid Angiosarcoma Originating from the Skull Head Neck Pathol [online] , 7(2):159-162 [viewed 25 October 2014] Available from: doi:10.1007/s12105-012-0389-9