How should a physical exam be conducted for suspected acute subdural hematoma (SDH)?

Updated: Jul 26, 2018
  • Author: Richard J Meagher, MD; Chief Editor: Helmi L Lutsep, MD  more...
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Less commonly, the hemiparesis may be ipsilateral to the hematoma, possibly due to direct parenchymal injury or compression of the cerebral peduncle contralateral to the hematoma against the edge of the tentorium cerebelli (the Kernohan notch phenomenon). Therefore, if the findings are conflicting, the most reliable indicator (by examination) of the side of the hematoma is a dilated or nonreactive pupil, which appears on the same side as the hematoma.

Patients may have a lucid interval after developing a traumatic subdural hematoma. In addition, initial CT scan findings may be negative (ie, delayed intracranial hemorrhage).

Acute subdural hematomas most often occur over the cerebral hemispheres (convexity). However, they may also be found between the hemispheres along the falx (interhemispheric subdural hematoma), along the tentorium, or in the posterior fossa.

Interhemispheric subdural hematomas may be asymptomatic or manifest as headache, [27] impaired consciousness, or hemiparesis or monoparesis (more likely to affect the contralateral leg than arm). Interhemispheric subdurals are usually managed conservatively unless neurologic deterioration is found. [28]

Look for signs of a basilar skull fracture. These include bilateral periorbital ecchymoses (raccoon eyes) and retroauricular ecchymoses (Battle sign). Note the presence or absence of cerebrospinal (CSF) rhinorrhea or otorrhea.

Areas surrounding lacerations should be shaved and inspected. Patients with severe head injuries should be assumed to have a cervical spine (C-spine) injury; immobilize the patient until clinical and radiographic studies can prove otherwise.

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