Case Subdural Hematom Asep

7/27/2019 Case Subdural Hematom Asep

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Subdural Hematom

Asep Aminudin AzizPembimbing : DR.dr. M.Z. Arifin . SpBS(K)


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Tn. Romlan/73 thn// 13060729/Trauma/MZKU : Penurunan kesadaran

AK:

2 jam SMRS ketika pasien sedang berjalan didaerah Husein Bandung tiba-tiba

pasien tertabrak motor dari arah belakang, sehingga pasien terjatuh dengan kepala

membentur aspal. Riwayat pingsan (+), muntah (-), perdarahan telinga, hidung dan mulut (-).

Pasien langsung dibawa ke emergensi RSHS

Survei Primer

A : Clear + C-spine control

B : Bentuk dan gerak simetris, VBS kanan = kiri , RR : 20x/menit

C : HR : 82x/menit , TD 120/80 mmHg

D : GCS : E3M5V2 = 10 Pupil bulat anisokor ODS 3/5mm, RC +/+

Motorik : parese -/-

Survei Sekunder

At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasar subcutis

At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis


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Rontgen Kepala

tidak ada garis fraktur


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Head CT Scan (Hasan Sadikin ,14-6-2013)


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Head CT Scan :

Soft tissue swelling ar left

parietooccipital et left frontal

Bone discontinuity (-)

Sylfian fissure compressed

Sulcy and gyri compressed

Hyperdense mass crescent shape at

right frontotemporoparietal

Ventricle and cysterns are

compressed

Midline shift > 5 mm to the left


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Thorax x-ray:normal


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Lab :

WD/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome

frontotemporoparietal dextra (S06.5)+ vulnus laceratum at parietooccipital

sinistra (S01.0)

Th/ Craniotomy Evacuation

ICU Ward

Hb 14.4

HMT 42

Leko 13800

Trombo 193.000

GDS 137

Na 138

K 3.4

ur 30cr 1.05


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WD/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome

temporoparietooocipital dextra (S06.5)+ vulnus laceratum at parietooccipital

sinistra (S01.0)

DO : a/r ltemporoparietooccipital dextra:

- Duramater intact, bluish, tensed

- SDH clot 30 cc, lysis 5 cc, from Bridging vein

- GCS pre op : E3M5V2 = 10

- Interval op : 10 hours

Intra Operative Finding :


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Permasalahan

Bagaimana mekanisme truma pada pasien ini

karena pada pemeriksaan fisik ditemukan jejas

sebelah kiri sementara pada pemeriksaan CT

Scan kesan SDH sebelah kanan ?

Apakah indikasi opersi pada pasien ini ?

Bagaimana prosedur tindakan yang dilakukan

bila ditempat pelayanan tidak terdapat CT-

Scan


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PEMBAHASAN


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ResumeAnamnesis

/73tahun

2 jam SMRS mengalami kecelakaan lalu lintas, terjatuh,

kepala membentur aspal.

Pingsan (+)

Langsung ke RSHS


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Pemeriksaan fisik

GCS : E3M5V2 = 10 Pupil bulat an isokor ODS 3/5mm, RC+/+ , Motorik : parese -/-

At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasarsubcutis

At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasarsubcutis

CT scan kepala : SDH frontotemporoparietal dextra LAB: Hb: 14,4, L;13.800

Dx/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subduralhematome frontotemporoparietal dextra (S06.5)+ vulnuslaceratum at parietooccipital sinistra (S01.0)


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Mechanism of injury in head trauma

Direct trauma by compression or crushing

Acceleration-Deceleration Injuries Brain has inertia. For example, when a person falls backwards onto a hard floor, the

back of the persons head hits the floor and stops. The brain, however, is stillmoving until it strikes the inside of the skull. If the brain gets bruised, there isbleeding, also called a hemorrhage. This bleeding causes further damage to the

brain. The skull does not need to strike an object in order for the brain to get injured.

There are many situations in motor vehicle crashes where the forces aretransmitted through the brain without the skull hitting the dashboard, windshield,steering wheel or window.

Coup/Contrer-CoupInjuries:Related to acceleration-deceleration injuries(e.g injury totemporal lobe in contralateral temporal trauma)


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Subdural Hematoma

A subdural hematoma (SDH)is a form of traumatic braininjury in which blood gathersbetween the dura and the

arachnoid.


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Subdural Hematoma


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Subdural hematomas

Occur between the dura and the arachnoid mater.

Typically, low-pressure venous bleeding of bridging

veins (superior cerebral veins) (between the cortex andvenous sinuses) dissects the arachnoid away from thedura and layers out along the cerebral convexity

Can be acute, subacute or chronic

CT Scan shows a crescent shaped clot. It conforms tothe shape of the brain and the cranial vault, exhibitingconcave inner margins and convex outer margins


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a) Acute subdural hematomas

most common types of intracranial hematomas.

often occur in head trauma from falls and motor vehicle

accidents,assults. Associated with compression of the brain and cerebral edema and

which increase intracranial pressure

Mortality and morbidity are high

b) Subacute subdural hematomas Take a week for symptoms to develop.

c) Chronic subdural hematomas

develop over weeks or months.

occur mostly in old patients esp those taking antiplatelet andanticoagulant drugs and with brain atrophy.

common in alcoholics (susceptible to falls)

Increased intracranial pressure and cerabral edema are unusual.


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Acute Subdural Hematoma

Crescent shaped;Hyperdense, may contain hypodense foci due

to serum, CSF or active bleeding


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Diagnosis Radiographic findings

hyperdense crescent-shaped


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Diagnostic Imaging

Noncontrast head CT scan (imaging study ofchoice for acute SDH) The SDH appears as a hyperdense (white) crescentic

mass along the inner table of the skull, mostcommonly over the cerebral convexity in the parietalregion. The second most common area is above thetentorium cerebellum


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History

Usually involves moderately severe to severe blunthead trauma

Acute deceleration injury from a fall or motor vehicleaccident, but rarely associated with skull fracture

Generally loss of consciousness

Any degree or type of coagulopathy should heightensuspicion of SDH

Commonly seen in alcoholics because theyre proneto thrombocytopenia, prolonged bleeding times, and

blunt head trauma Patients on anticoagulants can develop SDH with

minimal trauma and warrant a lowered threshold forobtaining a head CT scan


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Epidemiology

Trauma

- Frequency is related directly to the incidence of

blunt head trauma

-Its the most common type of intracranial mass

lesion, occurring in about a third of those withsevere head injuries

Acquire coagulopathies

Anticoagulation therapy Congenital bleeding disorders

Arteriovenous malformations

Aneurysm rupture


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Mortality/Age

Mortality Simple SDH (no parenchymal injury) is associated

with a mortality rate of about 20% Complicated SDH (parenchymal injury) is

associated with a mortality rate of about 50% Age Its associated with age factors related to the risk

of blunt head trauma

More common in people older than 60 years(bridging veins are more easily damaged/falls aremore common)

Bilateral SDHs are more common in infants sinceadhesions existing in the subdural space are

absent at birth


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Diagnosis Clinical manifestations

Headache

Nausea Vomiting Alteration of consciousness orneurological status Pupillary dilatation Focal neurological deficit Intracranial shift or herniation

Note:

For people taking anticoagulants e.g aspirin, the possibility of developing

intracranial hematomas from minor head injuries is increased.


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Treatment

Subdural hematomas

Symptoms: persistent headache, fluctuating drowsiness, confusion,memory changes, paralysis on the side of the body opposite thehematoma, and speech or language impairment.

Small ones require no treatment because the blood is absorbed onits own.

Large ones removed by surgery, (a drain is usually inserted and leftin place for several days).

monitored closely for recurrences.


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Treatment Surgical evacuation

Indications

Significant mass effect

Thickness of hematoma > 10 mm

Midline shift > 5 mm

Decrease in GCS score by 2 or more

Loss of pupillary reactivity or pupillary dilatation


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Outcomes Degree ofmass effect is more importantthan

Extracerebral mass lesions

Associated factor

age, time to evacuation, admission GCS score,

hypoxia or hypotention, extent of primary brain

injury, duration of coma, mechanism of injury,

present of coagulopathy


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Thank you


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NP 1. Mr Romlan/73 yo// 13060729/Trauma/MZ

CC : decreased of conciousnessHistory :

2 hours prior to admission, when he was walking at Husein area, suddenly he wasstrucked by motorcycle from behind. he fell down and him head hit the ground.History of unconscious (+), vomiting (-), bleeding from ear (-), nose (+) and mouth (-).he was brought direcly to Emergency Hasan Sadikin Hospital.

Primary Survey :

A : Clear + C-Spine control

B : Shape and movement simmetrycal ; Rh -/- ; RR = 20x/m

C : BP : 120/90 mmHg PR : 82 x/m

D : GCS E3M5V2 = 10

Pupil round unequal ODS 3/5 mm LR +/+Motoric : no paresis

Secondary Survey :

At left parietal : hematome (+), VL size 3x1x1 based on subcutis

At Left occipital : vulvus laceratum (+) size 5x1x1 cm based on subcutis


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Head CT Scan (Hasan Sadikin ,14-6-2013)


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Head CT Scan :

Soft tissue swelling ar left

parietooccipital et left frontal

Bone discontinuity (-)

Sylfian fissure compressed

Sulcy and gyri compressed

Hyperdense mass crescent shape at

right frontotemporoparietal

Ventricle and cysterns are

compressed

Midline shift > 5 mm to the left


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Thorax x-ray: within normal limit


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Lab :

WD/ moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left

temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital

(S01.0)


ICU Ward

GCS this morning E3M6V5 = 14

Hb 14.4

HMT 42

Leko 13800

Trombo 193.000

GDS 137

Na 138

K 3.4

ur 30cr 1.05


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WD/ moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left

temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital (S01.0)


DO : a/r left temporoparietooccipital :

- Duramater intact, bluish, tensed- SDH clot 30 cc, lysis 5 cc, from Bridging vein

- GCS pre op : E3M5V2 = 10

- Interval op : 10 hours

Intra Operative Finding :

Case Subdural Hematom Asep

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