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Subdural Haematoma DRAFT

Checked: 09-09-2025 by Jenny Henry Next Review: 09-09-2027

Overview

An acute subdural haematoma (SDH) is usually diagnosed in the context of a significant brain injury, i.e. after trauma.

A chronic subdural haematoma usually presents about 2-3 weeks following the provoking trauma. The initial injury may be relatively trivial (or forgotten), particularly in an older patient on anticoagulants, or in the context of alcohol misuse (1).

SDH is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the haematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of SDH can be inferred by neurological decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (CT or MRI). (2)

SDH has a variable disease course, depending on size of haematoma, age of the patient, presenting neurological signs/symptoms, presence of underlying coagulopathy or neoplasm, and associated injuries.

Surgical therapy is usually indicated for acute or chronic SDHs that are expansile or causing neurological deficit. Observation may be employed for small, stable SDHs that are not causing neurological compromise. (2)

Red Flags

Acute SDH

Patient with acute head injury and suspected SDH should be referred to the nearest ED for assessment and imaging if indicated.

Chronic/sub-acute SDH

Patients with a recent history of head injury any of the following signs and symptoms should also warrant urgent assessment:

new neurological deficits
worsening/debilitating headaches associated with nausea or vomiting
confusion or decline in mobility.

These can be features of further injury or a developing chronic subdural haematoma and warrant urgent assessment in a primary or emergency care setting.

Children and Elderly

SDH in children and elderly patients may raise the possibility of non-accidental injury (1).

Referral

Chronic Subdural Haemorrhage (CSDH)

If there is recent imaging demonstrating a CSDH, and the patient is presenting acutely with symptoms such as confusion, headaches or lateralising neurology, please refer urgently to on-call via Referapatient.

If there is no recent imaging, the patient will need to be seen and assessed in the nearest Emergency Department who will liaise with the neurosurgery service.

If this is an incidental finding without concerning symptoms, please refer to the joint geriatrics/interventional neuroradiology service team for assessment by emailing GeriatricTraumaConsultants@nbt.nhs.uk . They can assess whether the patient would benefit from an MMA embolisation.

Subdural hygromas describe an expansion of the subdural CSF spaces and are an incidental finding in the elderly population - they do not require intervention or follow up.

Follow up

Recovery after a conservatively or surgically managed acute subdural haematoma can be prolonged and it is not unusual for patients to experience persistent symptoms, such as headaches, dizziness, ‘brain fog’, fatigue and difficulty concentrating.

Patients who suffer from significant persistent post-head injury symptoms can be referred to the Head Injury Therapy Unit.

Resources

(1) Subdural Haematoma: Symptoms and Treatment | Doctor

(2) Subdural haematoma - Symptoms, diagnosis and treatment | BMJ Best Practice

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