What are the differential diagnoses and next diagnostic steps for a suspected Subdural Hematoma (SDH)?

From the Guidelines

The next diagnostic step for a patient with suspected subdural hematoma, particularly when there is a high index of suspicion for spinal CSF leak, is to perform an MRI of the brain with contrast and whole spine. This approach is supported by the multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension 1. The differential diagnosis for subdural hematoma includes epidural hematoma, subarachnoid hemorrhage, intracerebral hemorrhage, brain contusion, and cerebral infarction.

When evaluating a patient with subdural hematoma, it is crucial to consider the clinical context, including history of orthostatic headache, absence of trauma, coagulopathy, or alcohol misuse, as these factors can guide the diagnostic approach. For instance, patients with small or asymptomatic hematomas can be managed conservatively while treating the underlying CSF leak, as recommended by the guideline 1. However, symptomatic hematomas with significant mass effect may require more aggressive management, such as burr hole drainage in conjunction with treating the leak.

Key diagnostic considerations include:

• Imaging studies: MRI of the brain with contrast and whole spine to investigate spinal CSF leak
• Laboratory tests: complete blood count, coagulation profile, and specific factor assays if coagulopathy is suspected
• Clinical assessment: neurological examination with Glasgow Coma Scale scoring and pupillary response evaluation These diagnostic steps are essential to promptly identify the presence and extent of the hematoma, as well as any associated complications, and to guide appropriate management to prevent morbidity and mortality. The guideline 1 emphasizes the importance of a multidisciplinary approach to diagnosis and management, highlighting the need for careful consideration of the underlying cause of the subdural hematoma.

From the Research

Differential Diagnosis of Subdural Hematoma

• Subdural hematomas (SDH) can be caused by various factors, including trauma, anticoagulant/antiaggregant use, arterial rupture, oncologic hemorrhages, intracranial hypotension, and idiopathic hemorrhages 2
• The disease has acute, subacute, and chronic forms, and management of the disease changes according to the etiology of the lesion 2
• Patients with SDH may present with altered mental status, focal neurologic deficits, and other symptoms, making it essential to consider SDH in the differential diagnosis of patients with these symptoms 3, 4

Next Diagnostic Steps

• Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg 3
• Expedited acquisition of imaging, such as CT or MRI, is necessary to identify a space-occupying lesion and confirm the diagnosis of SDH 3, 4
• Patients may require rapid sequence intubation, anti-seizure medications, and reversal of antiplatelet medications or anticoagulation if neurosurgical interventions are anticipated 3
• The use of scoring systems, such as the acute SDH score, can help guide surgical decision-making and predict outcomes in patients with SDH 5