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Subdural Hematoma / Intracranial Hematoma

Definition :
Although head injuries can be minor, an intracranial hematoma is a serious and possibly life-threatening condition that often requires immediate treatment.

Your brain floats within your skull, surrounded by fluid that cushions it from the bounces of everyday movement. But the fluid may not be able to absorb the force of a sudden blow or a quick stop. In these situations, your brain may slide forcefully against the inner wall of your skull and become bruised.

An intracranial hematoma occurs when a blood vessel ruptures within your brain or between your skull and your brain. The collection of blood (hematoma) compresses your brain tissue.

Treating an intracranial hematoma often requires surgery to remove the blood. However, a smaller intracranial hematoma may not require surgery.

Causes :
The cause of intracranial bleeding (hemorrhage) is an injury to the head, often as a result of an automobile or motorcycle accident or a seemingly trivial event, such as bumping your head. Mild head trauma is more likely to cause a hematoma if you're an older adult. There may be no open wound, bruise or other outward sign.

If a hematoma results from the injury to your head, it

may occur as a subdural hematoma, an epidural hematoma or an intraparenchymal hematoma.

Subdural hematoma
This occurs when blood vessels — usually veins — rupture between your brain and the outermost of three membrane layers that cover your brain (dura mater). The leaking blood forms a hematoma that compresses the brain tissue. If the hematoma keeps growing, a progressive decline in consciousness occurs, possibly resulting in death.

There are three types of subdural hematomas :

  • Acute. This type is the most serious and potentially life-threatening. It's generally caused by a severe head injury, and signs and symptoms usually appear immediately.
  • Subacute. In subacute subdural hematoma, signs and symptoms take longer to appear, generally several hours.
  • Chronic. Less-severe head injuries may cause a chronic subdural hematoma. Bleeding from chronic subdural hematoma may be much slower, and symptoms may take days, or even months, to appear.

All three types require medical attention as soon as signs and symptoms are apparent, or permanent brain damage may result.

The risk of subdural hematoma is greater for people who use aspirin or anticoagulants daily, who are alcoholics, or who are either very young or very old.

Epidural hematoma
Also called an extradural hematoma, this type occurs when a blood vessel — usually an artery — ruptures between the outer surface of the dura mater and the skull. The blood vessel usually is damaged by a skull fracture. Blood then leaks between the dura mater and the skull to form a mass that compresses the brain tissue.

The risk of dying of an epidural hematoma is substantial unless prompt treatment occurs. Some people with this type of injury may remain conscious, but most become drowsy or comatose from the moment of trauma.

Epidural hematomas are more common in children and teenagers. They are often the result of motorcycle, automobile or other traumatic accidents.

Intraparenchymal hematoma
This type of hematoma, also known as intracerebral hematoma, occurs when blood pools in the brain. After a head trauma, there may be multiple severe intraparenchymal hematomas.

The trauma that causes intraparenchymal hematomas is often responsible for what are called white matter shear injuries. These injuries occur after a trauma literally tears axons in the brain's white matter. Axons are the connections that carry electrical impulses, or messages, from the neurons in the brain to the rest of the body. When this connection is sheared, serious brain damage can result because the neurons can no longer communicate.

Trauma isn't the only cause of intraparenchymal hematoma. Other causes include :

  • Blood vessel disorders, such as arteriovenous malformation (AVM) or aneurysm
  • Long-term hypertension
  • Neurological conditions, such as cerebral amyloid angiopathy
  • Brain tumors
  • Liver disease
  • Use of blood thinners
  • Certain autoimmune diseases
  • Bleeding disorders, such as hemophilia, leukemia and sickle cell anemia

When to seek medical advice :
An intracranial hematoma can be life-threatening. Emergency medical treatment often is necessary.

Seek medical advice after any significant blow to the head in which you lose consciousness or experience any of the signs and symptoms that may indicate an intracranial hematoma. Although symptoms of intracranial hematoma may not be immediately apparent, watch closely for subsequent physical, mental and emotional changes.

In addition, tell a family member or a close friend if you experience any type of head trauma. Because memory loss often is associated with head trauma, you may forget that you even suffered a blow to the head. An alerted friend, family member or work colleague may be more likely to recognize the warning signs and arrange for prompt medical attention if aware of your history.

Symptoms :
Signs and symptoms of an intracranial hematoma may occur from immediately to several weeks or longer after a blow to your head. As time progresses, pressure on your brain increases, producing some or all of the following signs and Symptoms:

  • Headache
  • Nausea
  • Vomiting
  • Drowsiness
  • Dizziness
  • Confusion
  • Slurred speech or loss of ability to speak
  • Pupils of unequal size
  • Weakness in limbs on one side of your body

As more and more blood fills your brain or the narrow space between your brain and skull, other signs and symptoms may become apparent, such as :

  • Lethargy
  • Seizures
  • Unconsciousness
Diagnosis :
Diagnosing a hematoma can be difficult. However, doctors generally presume that the progressive loss of consciousness after a head injury is caused by a hemorrhage inside the skull until proved otherwise.

The best method to define the position and size of a hematoma is by an imaging technique. These include :

  • Computerized tomography (CT) scan. A CT scan uses a sophisticated X-ray machine linked to a computer to produce detailed images of your brain. You lie still on a movable table that's guided into what looks like an enormous doughnut where the images are taken.
  • Magnetic resonance imaging (MRI) scan. An MRI scan is done using a large magnet and radio waves to make computerized images. During an MRI scan, you lie on a movable table that's guided into a tube, or tunnel.

CT and MRI scans are painless.

Hematoma treatment often requires surgery. The type of surgery depends on the characteristics of your hematoma. Options include :

  • Perforation. If the blood is localized and isn't clotting excessively, your doctor may create a hole through your skull (perforation) and then remove the liquid by suction.
  • Craniotomy. Large hematomas may require that a section of your skull be opened (craniotomy) to remove the blood.

Some subdural hematomas don't need to be removed because they're small and produce no signs or symptoms.

Doctors may use medications, such as corticosteroids and diuretics, to control brain swelling (edema) after a head injury.

After surgery, your doctor may prescribe anticonvulsant drugs, such as phenytoin (Dilantin), to control or prevent post-traumatic seizures. Seizures can begin as late as 24 months after the trauma. Amnesia, attention difficulties, anxiety and headache may occur and continue for some time.

Recovery after an intracranial hematoma can be prolonged and may be incomplete. In adults, most recovery takes place within the first six months after the injury. Children usually recover faster and more completely than adults do.

These steps may help to prevent or minimize head injury :

  • Use recreational safety equipment. Wear appropriate and properly fitting safety equipment during sports, including a helmet when bicycling, motorcycling, skiing, horseback riding, skating or doing any activity that may result in head injury.
  • Buckle your seat belt. Doing so may prevent or minimize damage to your head in a motor vehicle accident.
  • Protect your kids. To protect children, use properly fitting car seats, pad countertops and edges of tables, block off stairways, tether heavy furniture or appliances to the wall to prevent tipping, and keep children from climbing on unsafe or unsteady objects.
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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