Spectrum of Subdurals

History and Physical

A 16-year-old male experienced head injury while playing tackle football, followed by increasing headache.

Diagnostic Workup

Head CT showed a left holohemispheric subdural hematoma with rightward shift ( Fig. 67.1 ). The patient went to the operating room for decompression.

Two coronal C T slices side by side with arrows that mark frontal extraaxial densities and arrowheads that mark midline shift in opposite directions. — Fig. 67.1

Clinical Differential Diagnoses

Posttraumatic headache can be seen with intracranial hemorrhage, infarct, infection, seizures, and autoimmune conditions.

Imaging Differential Diagnoses

Posttraumatic intracranial hemorrhage can be epidural, subdural, subarachnoid, and/or parenchymal.

Other extra-axial conditions with mass effect include tumors and infection.

Final Diagnosis

Subdural hematoma.

Discussion

Subdural hematomas result from cortical venous injury with collection of blood products between the dura and arachnoid mater. They have a crescentic morphology that can cross sutures and track along dural reflections. Subdural hematomas are usually characterized by location, size and mass effect, and time since the inciting event (acute, subacute, chronic).

In children with normal brain volumes, development of subdurals usually requires severe accidental or nonaccidental trauma. However, in patients with large extra-axial spaces, bleeding disorders, or anticoagulation, subdurals can occur spontaneously or following minor trauma.

Clinical Red Flags

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Subdural hematomas can appear immediately or up to 4 weeks after an injury.
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In infants with malleable sutures, there may be a marked increase in head circumference.
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Abusive head trauma (AHT) can present with subdural hematomas, hygromas, and retinal hemorrhages.

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