Recognizing Subdural Hemorrhage in Older Adults
SOURCE: Topics in Integrative Health Care 2010; 1 (2)
By: Mark T. Pfefer, RN, MS, DC and Richard Strunk MS, DC
A subdural hematoma, also known as a subdural hemorrhage (SDH) is caused by a post-traumatic accumulation of blood within the potential space between the dura mater and the arachnoid layer covering the brain. Chronic SDH is much more common in the elderly. Patients can have a good outcome with neurosurgical management if the conditions is promptly recognized. All health care providers, as well as nursing home staff, should be aware of this condition because older patients presenting with headache and/or other neurologic complaints need careful assessment to identify SDH.
Keywords: subdural hematoma; subdural hemorrhage; chronic subdural hemorrhage; headache
Definition and Etiology
A subdural hematoma, also known as a subdural hemorrhage (SDH) is caused by a post-traumatic accumulation of blood within the potential space between the dura mater and the arachnoid layer covering the brain. All health care providers, especially those who frequently treat patients with musculoskeletal complaints, as well as nursing home staff, should be aware of this condition because older patients presenting with headache and/or other neurologic complaints need careful assessment. SDH should be considered in the differential assessment of any older patient presenting for care following trauma as it has been associated with minor head injury or falls, even those not involving direct trauma to the head.  In fact, absence of direct trauma to the head is associated with up to half of all cases of SDH, and a case has been reported in an adult following a roller coaster ride.  Based upon this it should be assumed that motor vehicle collisions could generate forces sufficient to cause SDH in older patients.
There are two types of subdural hematomas: acute and chronic. Acute bleeding is usually associated with severe head trauma and the mortality rate is high.  Chronic SDH can be caused by less severe trauma and symptoms may take days or weeks to appear. In contrast to epidural hematomas, which are caused by arterial bleeding, SDH involves tearing of bridging veins that cross the subdural space. Normal aging is associated with brain atrophy and this allows for increased strain on the bridging veins with movement and trauma.  Chronic SDH is much more common in the elderly and patients can have a good outcome with neurosurgical management if promptly recognized.
Signs and Symptoms
Signs and symptoms in sub-acute and chronic SDH may take days, weeks or months to develop and can be quite diverse. Signs and symptoms can be non-specific and can include headache, confusion, alteration in level of consciousness or may include focal neurological deficit. In large bleeds, signs of increased intracranial pressure with focal neurological deficits may be present. A patient may be asymptomatic initially following a traumatic head injury and symptoms can appear or progress later.
Symptoms of SDH include headache, dizziness, vomiting, drowsiness, lethargy, progressive decrease in level of consciousness, confusion, anisocoria (unequal pupils), weakness in limbs, seizure, and slurred speech. Varying levels of confusion and dementia are not uncommon in the elderly, which makes the diagnosis more difficult, but the most common presenting symptoms are headache, progressive neurological deficit and confusion.  A high level of concern is indicated in older patients presenting with neurologic deficits who have had repeated falls, head trauma (even minor), and in patients taking anticoagulant medication or patients with history of alcohol abuse.
SDH can lead to significant neurologic deficit and death so prompt medical attention is mandatory. Patients with suspected SDH will typically initially be evaluated with CT scan in an emergency center. CT findings typically demonstrate a crescent-shaped appearance of the hematoma with the concave surface away from the skull. Unlike epidural hematoma, SDH can involve overly a large portion of the cerebral hemisphere, crossing suture lines. 
Treatment of the SDH varies with the severity of the bleeding and the underlying health of the patient. In minor bleeding the patient will be monitored closely and may be administered medications to control brain swelling. If the patient is healthy and can tolerate surgery, and/or if the bleeding is severe, surgery is typically performed using a burr hole drill to allow drainage of the blood.  In some cases, a craniotomy is performed to decompress and drain the hematoma. 
Chiropractors and other practitioners who provide manual therapies should heighten their level of caution when adults and older adults present for care following any kind of head trauma or complaining of new onset headache, decrease in level of consciousness, or any type of focal neurologic finding.
Table 1 lists key points related to presenting symptomatology related to SDH.
Heightened caution is also indicated for all adult patients who are taking anticoagulant medication. Community dwelling elders and nursing home patients are often at risk for falls and are at heightened risk for SDH.
Table 1. Key Points. Subdural hemorrhage is typically caused by tearing of bridging veins, which can present with a variety of neurologic complaints, such as:
- Alteration of consciousness
- Dementia or behavioral changes
- Weakness in limbs
- Slurred speech
- Other focal neurologic deficit or cortical dysfunction
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