What is the best course of action for a patient experiencing dizziness after trauma with a subgaleal hematoma?

Management of Dizziness After Trauma with Subgaleal Hematoma

All patients with dizziness following head trauma and subgaleal hematoma require immediate non-contrast CT scan to rule out intracranial hemorrhage, particularly subdural hematoma, which can be life-threatening and requires urgent neurosurgical evaluation. 1, 2, 3

Immediate Diagnostic Workup

Obtain urgent non-contrast head CT to exclude:

• Subdural hematoma (which may coexist with subgaleal hematoma and requires neurosurgical consultation regardless of size) 1, 3
• Subarachnoid hemorrhage (catastrophic emergency with >40% mortality requiring immediate neurosurgical intervention and vascular imaging) 3
• Skull fractures (particularly skull base fractures that can cause dizziness through vestibular injury) 4, 5
• Intracranial mass effect or midline shift 2, 3

Complete neurological assessment including:

• Glasgow Coma Scale score 2
• Pupillary examination 2
• Focal neurological deficits 2
• Vestibular function testing if intracranial pathology is excluded 5

Verify anticoagulant or antiplatelet use, as these medications dramatically increase risk of both subgaleal hematoma expansion and intracranial hemorrhage 2, 4

Critical Decision Point: CT Results

If CT Shows Subdural Hematoma or Other Intracranial Pathology:

Immediate neurosurgical consultation is mandatory - do not independently decide on conservative management 1

• Subdural hematoma >10 mm thickness requires urgent surgical evacuation 1
• Any subdural hematoma with midline shift >5 mm requires surgical intervention 2
• Even small subdural hematomas (<5 mm) require neurosurgical assessment as they can expand rapidly, especially in anticoagulated patients 1, 2

Maintain systolic blood pressure >100 mmHg or mean arterial pressure 80-110 mmHg during evaluation and transfer to prevent secondary brain injury 6, 1, 3

Maintain euvolemia to optimize cerebral perfusion 1, 2

Reverse anticoagulation immediately if applicable 2

If CT Shows Isolated Subgaleal Hematoma Without Intracranial Injury:

Conservative management is appropriate for isolated subgaleal hematoma, as most resolve spontaneously within 4 weeks without intervention 7, 4

• Simple observation with compression dressing is first-line treatment 7, 4
• Monitor hematocrit if hematoma is large, as significant blood loss can occur requiring transfusion 4, 8
• Aspiration or drainage is reserved for: compressive complications (airway obstruction, orbital compartment syndrome), infection, or refractory cases not responding to conservative measures 4, 9, 8

Address dizziness symptomatically once intracranial pathology is excluded:

• Dizziness may result from vestibular injury, cervical strain, or post-concussive syndrome 5
• Consider cervical spine imaging if neck pain accompanies dizziness, as spinal subdural hematoma can occur with head trauma 5

Common Pitfalls to Avoid

Never assume dizziness is benign without neuroimaging - intracranial hemorrhage can present with minimal symptoms initially but deteriorate rapidly 1, 2, 3

Do not delay CT to obtain laboratory results if patient is stable for transport 3

Avoid hypotension during evaluation, as cerebral perfusion pressure must be maintained to prevent secondary brain injury 6, 3

Do not rely on clinical examination alone to distinguish between isolated subgaleal hematoma and intracranial injury - CT is mandatory 3

In anticoagulated patients, maintain high suspicion for intracranial bleeding even with mild trauma, and consider repeat CT if clinical deterioration occurs 4

Special Considerations for Refractory Subgaleal Hematoma

If subgaleal hematoma persists or recurs despite conservative treatment:

• Consider endovascular coil embolization of feeding vessels followed by percutaneous aspiration 9
• Surgical drainage may be required for large hematomas causing pain, compressive symptoms, or infectious complications 8