History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include recent trauma, coagulopathy or anticoagulant use, and advanced age (>65 years).
evidence of trauma
Physical signs of trauma on the face, head, and neck are looked for. Scalp and face abrasions, lacerations, avulsions, or ecchymosis are important to note.
headache
May be a sign of increased intracranial pressure, but is also a common symptom in the absence of increased intracranial pressure (e.g., due to meningeal irritation).
nausea/vomiting
May be a sign of increased intracranial pressure.
diminished eye response
Forms part of the Glasgow Coma Scale, and ranges from spontaneous to none. Anisocoria (unequal pupil size) may be a sign of brainstem herniation.
diminished verbal response
Forms part of the Glasgow Coma Scale, and ranges from orientated, fluent, and coherent through to none. More difficult to assess in ventilated patients.
diminished motor response
Forms part of the Glasgow Coma Scale, and ranges from obeys commands to none. If the patient is able to follow commands, more subtle indicators of impaired motor function (e.g., the presence of a pronator drift) may be noted.
confusion
May be a sign of increased intracranial pressure or increasing midline shift.
Other diagnostic factors
common
loss of consciousness/decreased alertness
A sign of midline shift and herniation, which may be caused by subdural haematoma.
seizure
A sign of parenchymal irritation, which may be caused by subdural haematoma.
loss of bowel and bladder continence
Can occur in the setting of seizures or as cerebral dysfunction caused by subdural haematoma.
localised weakness
A sign of parenchymal dysfunction caused by subdural haematoma.
sensory changes
A sign of parenchymal dysfunction caused by subdural haematoma.
cognition changes
Can be a sign of parenchymal dysfunction or indicate a decline in level of alertness, in the setting of herniation caused by subdural haematoma.
speech or vision changes
A sign of cortical dysfunction caused by subdural haematoma.
otorrhoea
May indicate occult basilar skull fracture.
rhinorrhoea
May indicate occult basilar skull fracture.
Risk factors
strong
recent trauma
Often obvious in the case of acute subdural haematoma (SDH), although may be trivial trauma (e.g., falls or bumps to the head) and not always recognised or reported. Trivial trauma becomes especially important for patients taking anticoagulants. Patients with chronic SDHs may provide a history of frequent falls. A preceding traumatic event has been identified in a range of 50% to 77% of cases of chronic SDH.[26]
coagulopathy and anticoagulant use
Risk factor for spontaneous, traumatic acute and chronic SDH.[10][13][14][28][29]
History-taking should include questions about use of antiplatelets or anticoagulants, easy bruising, or difficulty stopping bleeding from small cuts or scrapes. One case-control study found the highest odds of SDH was associated with combined use of a vitamin K antagonist and an antiplatelet drug.[14]
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