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Imaging in Subdural Hematoma

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Imaging in Subdural Hematoma

Author: Andrew L Wagner, MD; Chief Editor: L Gill Naul, MD more... Updated: May 27, 2011

Computed Tomography
CT scan findings in subdural hematomas depend on the age of the hemorrhage (see the image below).[3, 4, 5]

Computed tomography (CT) scan demonstrating a patient w ith subdural hematomas of varying ages. This patient had a CT scan 1 w eek prior that demonstrated a chronic subdural hematoma (represented by the low density fluid on this study). Over the next w eek, his clinical condition progressively declined, then he collapsed shortly before this image w as obtained. The gray blood represents subacute hemorrhage, w hereas the w hite blood represents acute.

In the acute phase, subdural hematomas appear as a crescent-shaped extra-axial collection with increased attenuation that, when large enough, causes effacement of the adjacent sulci and midline shift. The attenuation changes as the hematoma ages (see the images below).[6, 7]

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Imaging in Subdural Hematoma

Late subacute subdural hematoma has decreased attenuation compared w ith adjacent brain tissue. Attenuation of the hematoma remains higher than that of cerebrospinal fluid.

Computed tomography scan in a patient w ith a subacute right frontal subdural hematoma. The blood has the same attenuation as that of the adjacent gray matter and is difficult to distinguish. Note that the gray matterw hite matter junction is displaced medially, and midline shift is seen, indicating the presence of a space-occupying extra-axial lesion.

Subacute subdural hematomas may be difficult to detect because they may have isoattenuation compared with adjacent gray matter. Displacement of the gray matterwhite matter junction is an important sign that indicates the presence of a space-occupying lesion. Although often administered in the past to help detect displacement of cortical vessels, contrast medium is not necessary with the capabilities of current scanners. Chronic subdural hematomas (see the image below) have isoattenuation relative to the cerebrospinal fluid (CSF). In rare cases, such hematomas may calcify, resulting in an unusual appearance that can be mistaken for a calcified mass.

Late subacute-to-chronic subdural hematoma w ith a blood-fluid level indicating acute hemorrhage into the chronic collection.

Unlike epidural hematomas, subdural hematomas are not restricted by dural tethering at the cranial sutures; they can cross suture lines and continue along the falx and tentorium (see the image below). However, they do not cross the midline because of the meningeal reflections.
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Tentorial subdural hematoma in an adult w ith trauma. In children w ith this pattern of injury, abuse should be considered.

When a subdural hematoma is discovered on a CT scan, it is important to check for the presence of other related injuries, such as skull fracture (see the first image below), intraparenchymal contusions, and subarachnoid blood (see the second image below). The presence of adjacent parenchymal injury in patients with a subdural hematoma is the most important factor in predicting their clinical outcome.

Axial head computed tomography scan demonstrates a skull fracture w ith an adjacent, small subdural hematoma. Window and level values are w idened over standard values, w hich aids in the detection of small hemorrhages.

Subdural hematoma w ith adjacent subarachnoid hemorrhage w as the result of a ruptured middle cerebral artery aneurysm. Aneurysms are unusual causes of subdural hematomas.

Rebleeding into subdural hematomas also may occur and is depicted as a layer of high-attenuation hemorrhage within a lower attenuation hematoma.

Degree of confidence
Differentiating subdural from epidural hematomas may be difficult when the hemorrhage is small, because the image of the blood may not demonstrate a typical shape in either condition. Follow-up imaging to ensure that the hematoma is not expanding and to check for an adjacent skull fracture is typical.

False positives/negatives

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Imaging in Subdural Hematoma

Small subdural hematomas may not be depicted because the attenuation may be similar to the adjacent inner table of the skull. Viewing the images with a wider window and level (eg, 240 and 80 HU) assists in detection in these cases; however, CT scanning fails to depict a certain number of small hemorrhages. Gentry et al found that only 53% of acute and subacute subdural hematomas were revealed on CT scan studies compared with MRI; however, this study was performed using older CT technology.[8, 9] In older patients with cerebral atrophy, an appearance of bilateral frontal subdural hygromas may be seen when the patient is in the supine position. However, the lack of mass effect and the presence of general atrophy suggest that this appearance is merely the result of settling of the atrophic brain rather than a pathologic subdural collection. A similar finding can be seen in young children (benign enlargement of the subarachnoid space), which should resolve in the first few years of life (see the image below).

Axial computed tomography scan demonstrates the benign enlargement of the subarachnoid space that occurs in children. The extraaxial fluid does not cause mass effect and normally resolves w ithin the first 2 years of life.

Posttraumatic subdural hygromas can also be confused with chronic subdural hematomas. These develop days or weeks following trauma and result from tears in the arachnoid and resulting leakage of CSF into the subdural space. They are self-limited and usually resolve after several months.

Contributor Information and Disclosures

Author Andrew L Wagner, MD Assistant Professor of Radiology, Instructional Faculty, University of Virginia School of Medicine; Director of Neuroradiology, Department of Radiology, Rockingham Memorial Hospital Andrew L Wagner, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, and Radiological Society of North America Disclosure: Nothing to disclose. Specialty Editor Board Robert A Koenigsberg, DO, MSc, FAOCR Professor, Director of Neuroradiology, Program Director, Diagnostic Radiology and Neuroradiology Training Programs, Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine Robert A Koenigsberg, DO, MSc, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Neuroradiology, Radiological Society of North America, and Society of NeuroInterventional Surgery Disclosure: Nothing to disclose. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand Disclosure: Nothing to disclose.
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Imaging in Subdural Hematoma

Robert M Krasny, MD Resolution Imaging Medical Corporation Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America Disclosure: Nothing to disclose. Chief Editor L Gill Naul, MD Professor and Head, Department of Radiology, Texas A&M University College of Medicine; Chair, Department of Radiology, Chief, Section of Magnetic Resonance Imaging, Scott and White Memorial Hospital and Clinic L Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Texas Medical Association Disclosure: webmd Honoraria Other

References
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