Definition

A subdural hematoma is a type of bleeding that occurs inside the head. Within the cranial cavity, three layers separate the skull from the brain. This bleeding occurs in the layer beneath the skull but does not reach the brain. A torn vein usually causes bleeding and is often the result of a severe head injury. This is an emergency. The accumulation of blood in the cranial cavity can increase pressure inside the head and cause symptoms such as headaches, vomiting, seizures, and even death if not treated promptly.

Bleeding in the head is a relatively common condition because head injuries can cause it. In infants, subdural hematomas can occur when a baby experiences shaken baby syndrome. Subdural hematomas are classified based on the time of occurrence, ranging from acute (<72 hours), sub-acute (3-5 days), to chronic (occurring over weeks).

Causes

To understand the causes of subdural hematomas, we must know the layers between the skull and the brain. The first layer is the dura mater, which is connected to the second layer called the arachnoid layer. Below the arachnoid layer is the pia mater, which is interconnected with thin-walled veins. If an injury occurs, the blood vessels in these layers can rupture, causing bleeding and resulting in a subdural hematoma. The most common causes of subdural hematomas include:

• Head injuries, including blunt trauma and vigorous shaking of the head back and forth in infants, are known as shaken baby syndrome.
• Patients on blood thinners.
• Complications from medical procedures such as cerebrospinal fluid extraction.

Risk factor

Anyone can experience a subdural hematoma due to head injuries. Risk factors that can make a person more susceptible to bleeding in the brain layers include:

• Elderly individuals: The volume of the brain decreases with age, causing a gap between the protective layers of the brain and stretching the blood vessels. This condition makes an individual more prone to bleeding after minor injuries, such as a fall from a chair.
• Athletes in contact sports such as football players.
• Blood thinners: Patients on blood thinners have difficulty forming blood clots, making even minor injuries potentially serious.
• History of hemophilia: Hemophilia is a blood disorder where blood has difficulty clotting.
• History of alcohol consumption: Long-term alcohol consumption can damage the liver, which produces proteins essential for blood clotting.
• Infants: An infant's neck lacks the structure to support the head properly. Vigorous shaking of an infant's head can cause bleeding, known as shaken baby syndrome.

Symptoms

Bleeding in the head can occur over hours to weeks. Symptoms experienced are related to the extent of the bleeding in the brain layers. Early symptoms include:

• Persistent headache that does not improve with medication. Severe cases of bleeding usually cause more intense headaches.
• Confusion and a tendency to sleep.
• Nausea and vomiting.
• Changes in speech.
• Vision disturbances.
• Headache accompanied by difficulty walking.
• Weakness on one side of the body.
• Memory loss.
• Sudden behavioral changes.
• In infants, the head appears enlarged.

As the amount of blood in the cranial cavity increases and raises the pressure inside the head, symptoms such as seizures or paralysis on one or both sides of the body can occur, potentially leading to death. Paralysis on one side occurs in 40% of head bleeding cases. In some cases, symptoms may vary.

Diagnosis

When someone is suspected of having head bleeding, an interview is conducted to determine the cause of the bleeding, symptoms, and the patient's risk factors, such as blood thinner use. Physical examination is performed to check for potential nerve abnormalities. Recommended radiology examination includes a Computed Tomography Scan (CT scan). CT scan is preferred because it can visualize the brain within 5 minutes and is sensitive to detecting bleeding. Laboratory tests that can be performed include a complete blood count, blood clotting tests, blood typing, and electrolyte tests.

Management

In cases where the bleeding is minimal, a subdural hematoma can resolve spontaneously. Treatment may involve medication and rest. However, significant bleeding can gradually increase intracranial pressure. In cases of extensive blood accumulation, decompression (reducing head pressure) and removing the accumulated blood may be necessary. To remove accumulated blood, a tube can be inserted and left for several days until no more blood comes out. After treatment, additional examinations using magnetic resonance imaging (MRI) may be conducted to monitor treatment progress. Although surgery is the primary treatment option, several types of medications can be administered, including:

• Sedatives to assist in securing the airway.
• Medications to reduce intracranial pressure, such as Mannitol, administered via IV infusion.

Besides medication, patients must be under medical supervision to monitor symptoms and the potential worsening of their condition.

Complications

If head bleeding is left untreated, it can be serious and even life-threatening. There are other potential complications to watch out for too:

• Brain herniation: High intracranial pressure can shift and compress the brain, potentially causing death.
• Recurrent bleeding.
• Recurrent seizures.

The speed of complication onset depends on the extent of bleeding in the head.

Prevention

To prevent head injuries, always wear a helmet or head protection when engaging in risky activities such as riding. Using a safety belt in a car can prevent injuries during an accident.

When to see a doctor?

If you or a family member experiences a head injury accompanied by the following symptoms:

• Loss of consciousness for several minutes to hours.
• Worsening headache.
• Nausea and vomiting.
• Seizures.
• Paralysis on one or all sides of the body.
• Numbness in fingers and toes.
• Loss of coordination.
• Slurred speech.
• Confusion.

Immediately seek medical attention at the nearest healthcare facility for proper treatment. Timely and appropriate treatment for subdural hematomas can improve patient quality of life and prevent severe complications such as death.

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