Intracranial subdural hematoma in children: Clinical features, evaluation, and management

INTRODUCTION — Subdural hematoma (SDH) forms when there is hemorrhage into the potential space between the dura and the arachnoid membranes. SDH in children differs significantly from SDH in adults because abusive head injury is a common etiology, especially in pediatric patients <2 years of age [1]. In contrast to epidural hematoma (EDH), indications for operative management of SDH are less clear, and surgery is less likely to prevent morbidity and mortality. (See "Intracranial epidural hematoma in children".)

This review will discuss the clinical features, evaluation, and management of subdural hematoma in children. The epidemiology, anatomy, and pathophysiology of SDH in children and SDH in adults are discussed separately. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology" and "Subdural hematoma in adults: Etiology, clinical features, and diagnosis" and "Subdural hematoma in adults: Management and prognosis".)

CLINICAL FEATURES — A rapid overview summarizes the important clinical features and initial management of SDH in children (table 1).

History — In the abused infant or young child, SDH is frequently discovered after physical examination and imaging. The history usually does not provide a plausible mechanism for the severity of injury and may be misleading. Frequently no mention of trauma of any kind is given. Common presenting complaints include altered mental status, seizures, apnea, breathing difficulty, or sudden cardiopulmonary arrest. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'History'.)

Historical features may suggest an increased risk of SDH in patients with unintentional injury, such as:

●High risk trauma mechanism such as motor vehicle collision or fall from a significant height (>3 times patient height) (table 2)

●Seizure, confusion, headache, vomiting, or loss of consciousness

●Past medical history of predisposing illness, including (see "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology", section on 'Minor head injury'):

•Bleeding disorder (hemophilia, thrombocytopenia)

•Cerebral atrophy or treated hydrocephalus

•Arachnoid cyst

•Osteogenesis imperfecta

•Glutaric aciduria, type I

Physical examination — Because of the strong association between SDH and child abuse in infants and toddlers ≤2 years of age and because a history of head trauma is usually lacking, the clinician must maintain a high index of suspicion during physical examination of any child in this age group.

In children with unintentional head injury, SDH can manifest as an alteration of mental status or focal neurologic deficit. Other findings might include fullness of the fontanelle or a jump in head growth.

Up to 8 percent of neonates may develop a small SDH during labor and delivery but usually remain asymptomatic [1]. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology", section on 'Epidemiology'.)

Abusive head injury (shaken baby syndrome) — Abused infants with SDH are typically <2 years of age. External evidence of head injury, such as scalp hematoma, may be absent. These children demonstrate nonspecific clinical signs of brain injury, including:

●Irritability

●Vomiting

●Bulging anterior fontanelle

●Increased head circumference when compared with growth chart or prior measurements

●Pallor with anemia

●Lethargy, coma, or seizures

Large amounts of intracranial blood can accumulate prior to changes in the neurologic examination and may cause fever or hemorrhagic shock, particularly in infants with open fontanelles and cranial sutures.

Bradycardia and pupillary changes are late findings often associated with rapid neurologic deterioration and poor outcomes despite rapid intervention. Because of delay in seeking medical attention, abused children with SDH may also present in cardiopulmonary arrest. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Physical examination'.)

Retinal hemorrhages, skull and skeletal fractures commonly accompany SDH in children with abusive head injury (shaken baby syndrome) and indicate major traumatic force that usually does not match the history. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Physical child abuse: Diagnostic evaluation and management".)

Other signs of physical abuse that should be sought include:

●Unusual bruises (eg, loop mark, bite mark) (see "Physical child abuse: Diagnostic evaluation and management")

●Bruises in various stages of healing

●Cigarette burns

●Injuries to the genitalia

When abusive head injury is suspected, involvement of an experienced child protection team is crucial, and in many parts of the world (including the United States, United Kingdom, and Australia), reporting to a governmental agency is mandatory. (See "Physical child abuse: Diagnostic evaluation and management".)

Unintentional head injury — Intracranial bleeding should be suspected if there is a witnessed deterioration in neurologic status after an unintentional head injury. Depending upon the severity of traumatic injury, the child may present with a scalp hematoma and varying degrees of impaired consciousness and Glasgow Coma Score (GCS) (table 3). Often a small SDH is found by computed tomography (CT) of the head in patients who are neurologically intact. In these children, common symptoms include headache, vomiting, or irritability.

Infants with mild head injury and SDH should undergo evaluation for predisposing factors including bleeding tendency, osteogenesis imperfecta, and glutaric aciduria type 1 although abusive head injury is still the most likely etiology in these children. (See "Organic acidemias: An overview and specific defects", section on 'Glutaric acidemia type 1' and "Osteogenesis imperfecta: An overview".)

Other children will present in coma from large hematomas, possibly requiring urgent surgical evacuation. Lateralizing neurologic signs (eg, anisocoria, hemiparesis, hemiplegia) arise from compression of the third cranial nerve and brainstem. These are indicators of progression to cerebral uncal herniation. The side of the dilated pupil matches the side of the hematoma in roughly 90 percent of cases. The constellation of systemic hypertension, bradycardia, and respiratory depression (Cushing triad) is another late sign, and may be a preterminal event.

PRIMARY EVALUATION AND MANAGEMENT — A rapid overview summarizes the important clinical features and initial management of SDH (table 1).

Initial assessment and treatment — The order of priority in the initial assessment and treatment of the injured child with possible SDH is the same as for any trauma patient (table 4). (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.):

●A - Airway maintenance with cervical spine protection

●B - Breathing and ventilation

●C - Circulation with hemorrhage control

●D - Disability (evaluation of neurologic status)

●E - Exposure (complete visualization)/environmental control (prevention of hypothermia)

A rapid neurologic examination should focus on mental status using an age-appropriate GCS (table 3), pupillary findings, cranial nerves, and motor function. Patients with concerns for significant intracranial injury or increased ICP must be managed appropriately to reduce the likelihood of secondary brain injury from hypoxia, ischemia, and cerebral edema.

●The clinician should provide supplemental oxygen to keep saturation >95 percent.

●Cervical spine immobilization should be maintained throughout emergent patient care in all patients. Those patients with altered mental status should continue to be immobilized even if radiographic studies show no bony abnormality until the patient is awake and can be fully assessed.

●Head injured patients with compromised airway, inadequate breathing, or severe neurologic findings (GCS ≤8, pupillary abnormalities, neurologic deficit, or rapidly declining mental status) require early rapid sequence endotracheal intubation using measures to prevent increased ICP (table 5).

●Aggressive hyperventilation (PaCO2 <30 mmHg) may cause cerebral ischemia as the result of decreased cerebral blood flow. Consequently, PaCO2 should be maintained between 35 and 40 mmHg unless there are signs of impending herniation. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Breathing' and "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Rapid sequence intubation'.)

●Patients with hypotension require rapid fluid resuscitation to maintain cerebral perfusion (see "Trauma management: Approach to the unstable child", section on 'Circulation').

Neurosurgical consultation — Any pediatric trauma patient with a GCS ≤12 (table 3) warrants emergent consultation and evaluation by a neurosurgeon. Children with a GCS ≤8 should undergo intracranial ICP monitoring. Specific therapies targeted at increased ICP are ideally employed in consultation with a neurosurgeon and include sedation and osmotic therapy using mannitol or hypertonic saline infusion. These treatments are discussed separately. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis".)

Laboratory studies — To assess for anemia, bleeding tendency, and prepare for possible surgery, we recommend the following blood studies:

●Complete blood count with platelets

●Prothrombin time (PT)

●Partial thromboplastin time (PTT)

●International normalized ratio (INR)

●Bleeding time (if available)

●Type and cross

Other studies (eg, AST, ALT, and urinalysis) may be indicated in multiple trauma patients and suspected victims of abuse. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Laboratory studies' and "Physical child abuse: Diagnostic evaluation and management", section on 'Laboratory studies'.)

Due to the risk of herniation, lumbar puncture is contraindicated in cases where a space-occupying lesion such as SDH is suspected [2].

Radiographic imaging — On CT, a SDH typically appears concave as it spreads across the brain surface unrestricted by cranial sutures, whereas an EDH is lenticular and does not cross suture lines (image 1 and image 2). (See "Intracranial epidural hematoma in children".)

Abusive head injury — Neuroimaging is an essential component of the evaluation of children with suspected inflicted head injury. In addition to establishing the diagnosis, imaging may provide documentation of the extent and timing of injuries. Because it is rapidly available and quick, unenhanced computed tomography (CT) of the head is the initial study of choice (image 3). (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Imaging'.)

●Homogeneous hyperdense subdural hematoma is more frequent in cases of unintentional head trauma.

●Mixed-density subdural hematoma may be seen in cases of nonaccidental head injury due to repetitive injuries, but may be observed within 48 hours of unintentional head trauma.

●Interhemispheric hematomas and hematomas in multiple sites are seen almost exclusively in inflicted injury [3].

Depending on the degree of brain injury and size of hematoma, there may be associated uncal, subfalcine, or transtentorial herniation, as well as other signs of ischemia or hypoxia such as loss of grey-white distinctions in the brain on CT. In addition, EDH, cerebral contusion, and subarachnoid hemorrhage may be present.

Magnetic resonance imaging (MRI) is preferred for infants who are stable but require neuroimaging because of other injuries indicating physical abuse found on clinical examination and/or skeletal survey. In addition, MRI can be done in follow-up for patients with abnormal CT findings (image 3). (See "Physical child abuse: Diagnostic evaluation and management".)

Unintentional injury — As with any head injury, a patient who presents with altered mental status after a significant trauma warrants emergency neuroimaging. Unenhanced head CT tends to be the study of choice. Although it may offer less diagnostic accuracy than magnetic resonance imaging (MRI) for the detection of a subdural hematoma, CT detects SDH well enough to guide management and is more rapidly obtained [4,5]. In addition, it more accurately diagnoses skull fracture [6]. In some centers, rapid MRI is used in preference to CT, and should also adequately show the hemorrhage.

For clinically stable children with clear signs of extraaxial hemorrhage (ie, bleeding outside of the brain parenchyma) on CT, but for whom the space (epidural, subdural, or subarachnoid) in which the hemorrhage has occurred is less clear, it is often prudent to obtain further imaging.

●For children with an open anterior fontanelle, a bedside ultrasound with duplex Doppler may rapidly distinguish between subdural and subarachnoid hemorrhage by detecting the course of blood vessels through the extraaxial space.

●MRI, when the clinical situation allows, is the preferred modality because it accurately identifies the space involved and demarcates the associated brain injury, such as stroke or contusion (image 4) [3,4].

Making the distinction between enlarged subdural or subarachnoid space radiographically is important because the underlying cause can be significantly different. Subdural blood implies a higher likelihood of significant traumatic head injury as the etiology. Enlarged subarachnoid spaces may be normal variants.

Child protection — Diagnosis of a SDH in a child with no plausible mechanism of injury should prompt involvement of an experienced child protection team (eg, social worker, nurse, physician with more extensive experience in the management of child abuse), if available. In many parts of the world (including the United States, United Kingdom, and Australia), a mandatory report to appropriate governmental authorities is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

In addition, the medical care team should ensure that fundoscopic examination by an ophthalmologist to assess for retinal hemorrhages and skeletal survey occur once the patient's clinical status is stabilized. The safety of other children in the home must be ensured by local Child Protective Services. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Eye findings in children with abusive head trauma (AHT)".)

DEFINITIVE MANAGEMENT — In children with acute SDH, rapid evaluation and care by a neurosurgeon are key to optimal outcomes. If there is no neurosurgical coverage at the admitting hospital, the child must be resuscitated and promptly transferred to an appropriate institution. A rapid overview summarizes the important clinical features and initial management of SDH in children (table 1).

Operative decision — We recommend that most children with acute SDH, neurologic impairment, and midline shift on imaging undergo surgical evacuation. Frequently children who are comatose with severe brain swelling and signs of infarct on imaging are not good candidates for surgical evacuation of a SDH. This approach contrasts sharply with management of epidural hematoma in children where urgent surgery is always indicated in the presence of significant neurologic compromise.

The decision to perform surgery on children with SDH is based upon physical findings and the results of neuroimaging. No clear criteria for operative care exist and no controlled studies of operative approach in children have been performed. Due to the flexibility of the pediatric skull, the indications for surgery might occasionally differ from that of adults, but must be decided on a case by case basis by a neurosurgeon with pediatric expertise. (See "Subdural hematoma in adults: Management and prognosis", section on 'Surgical indications and approaches'.)

Relative to EDH, the clinical presentation and radiographic findings in SDH are much more varied, and the time since injury ranges from hours to weeks. Factors for deliberation include the clinical presentation, the size of the hematoma, and the appearance of the underlying brain injury.

●In most cases, children with acute, unilateral SDH, neurologic impairment, and midline shift on unenhanced head CT should undergo surgical evacuation. Depending on the size and location of the SDH, the timing (acute or chronic), and the presence of other brain abnormality on head CT, immediate surgery is not likely to improve outcome in some children. Therefore, some children with severe brain injury may not be surgical candidates despite the presence of subdural hematoma. (See 'Nonoperative management' below.)

●Although decompressive craniectomy has been used as a tool in the management of the refractory ICP in children with inflicted head injury, its use is not routine in all centers [7].

This measured approach to operative care in children with SDH contrasts with the urgent need to operate on every child with significant EDH and neurologic compromise. (See "Intracranial epidural hematoma in children".)

Timing of surgery — When surgery is indicated, evidence from observational studies in adults with SDH suggests that surgery within two to four hours after the onset of neurologic deterioration in patients with SDH is associated with a lower mortality than delayed surgery. (See "Subdural hematoma in adults: Management and prognosis", section on 'Timing of surgery'.)

Surgical procedures — When surgical intervention is required, craniotomy or craniectomy will successfully evacuate the SDH in approximately 80 percent of patients and is used for acute hematomas with or without associated brain swelling. Postoperative infection in up to 17 percent of children has been described [8].

●Subdural peritoneal shunt placement is used for chronic SDH that is unresponsive to subdural taps and eliminates the subdural hematoma in most cases [8,9]. Subsequent obstruction is seen in up to 14 percent of patients with an infection rate of 5 percent [9]. Many surgeons choose to remove the subdural shunt after three to six months to avoid long term complications, primarily infection. These shunts are needed in a minority of patients.

●Burr holes can also be used for drainage of chronic liquefied SDH, but will not work for large clotted hematomas.

Temporizing procedures — Some neurosurgeons perform subdural taps in stable patients with chronic subdural hematoma or subdural hygroma to facilitate resorption. As many as 42 percent go on to require further taps or another procedure [8,10], such as a subdural drain placement. For many patients, subdural taps or drain placement are performed as an intermediate step that helps determine the need for a more definitive procedure, such as placement of a subdural peritoneal shunt.

Nonoperative management — If at all possible, the decision to manage SDH nonoperatively should be made in conjunction with a neurosurgeon who understands the subtleties that would distinguish the more benign lesion from one that is a surgical emergency. In instances where neurosurgery is not physically available to the managing physician and transport to a higher level of care poses risk to the patient, phone consultation and remote review of the head CT by a neurosurgeon may assist in guiding proper patient disposition and care.

Frequently children who are comatose with severe brain swelling and infarction are not good candidates for surgical evacuation of a SDH. This situation contrasts sharply with EDH in children, for which urgent surgery is always indicated when significant neurologic compromise is present. (See 'Operative decision' above and "Intracranial epidural hematoma in children".)

Examples of children with SDH in whom medical management might be appropriate include:

●A comatose child with a small SDH and severe cerebral edema.

●Children with acute bilateral subdural hematoma after inflicted head injury. Surgical evacuation in these patients can lower ICP and improve cerebral hemodynamics [7,11]. Unfortunately, evacuation of the subdural in these cases may not significantly improve outcome, which is ultimately determined by severity of cerebral edema and primary brain injury (image 1) [8,12,13].

●Children who are minimally symptomatic with a small SDH.

Children managed nonoperatively should be observed in a facility where experienced pediatric trained personnel can monitor for neurologic changes. Patients with GCS ≤8 should have continuous intracranial monitoring of ICP during observation if the medical situation allows for safe insertion of the monitor. In addition, 24 hour emergency access to head CT and a properly equipped operating room are essential, as deterioration can occur at any time.

A repeat head CT should be obtained within 24 hours or sooner if concerning features exist on the initial head CT. In addition, significant clinical deterioration requires emergent repeat head CT. Observational studies in children show that reimaging with a head CT detects an increase in SDH size in up to 14 percent of patients and that 4 percent undergo surgical evacuation or other procedure based on this progression [14,15].

Because of the risk of marked change in the size of a SDH with neurologic sequelae, even asymptomatic children with a small SDH should generally be admitted to the hospital for observation and possible reimaging.

FOLLOW-UP — After recovery, children with SDH need regular follow-up with possible periodic imaging of the brain to monitor status of the hematoma. Some children may go on to develop a chronic subdural hematoma or subdural hygroma, which at times can be persistent [8,10]. In infants, following the head circumference is a very effective monitoring tool. Children should be restricted from activities such as contact sports or rough play until all SDH fluid collections have resolved. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology".)

Victims of inflicted head trauma and their siblings require social placement in a safe family environment and ongoing social and psychological support. (See "Child abuse: Social and medicolegal issues".)

Those patients with neurologic impairment after treatment of SDH should be referred for occupational and physical therapy.

Children with iron deficiency anemia from blood loss should receive replacement doses of iron. (See "Iron deficiency in infants and children <12 years: Treatment", section on 'Oral iron therapy'.)

OUTCOME — Based on small observational studies, outcomes following a SDH are best predicted by the neurologic state of the child on presentation [16].

●A neurologically intact child presenting with relatively subtle findings such as increased head circumference and/or bulging fontanelle can be predicted to have a reasonably good outcome, even if the hematoma is large.

●Children presenting with severe alterations in their level of consciousness and significant neurologic symptoms after unintentional head injury typically experience poor outcomes, independent of the size of the SDH, because of coexisting brain injury. In this respect, SDH differs substantially from EDH. Since an EDH often has little underlying brain injury, even a comatose, herniating patient can have an excellent outcome if rapid surgical intervention is achieved. (See "Intracranial epidural hematoma in children", section on 'Outcomes'.)

●Most victims of inflicted head injury with SDH have a poor outcome. In one series of 33 infants with SDH, most of whom had inflicted head injury, 75 percent died or had profound disability [17].

For the survivors, inflicted brain injury in children has both short and long term neurologic, behavioral, and cognitive consequences. As with unintentional injury, the best prognostic indicator for neurocognitive recovery after inflicted injury is neurologic condition on presentation. Delayed presentation to a medical facility, low Glasgow coma score at time of presentation, and prolonged duration of coma are all correlated with unfavorable outcomes. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Outcome'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma" and "Society guideline links: Child abuse and neglect".)

SUMMARY AND RECOMMENDATIONS

●Subdural hematoma (SDH) results from bleeding into the potential space between the dural and the arachnoidal membranes. On CT, a SDH appears concave as it spreads across the brain surface unrestricted by cranial sutures (image 1). (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology".)

●A rapid overview summarizes the important clinical features and initial management of SDH in children (table 1).

Clinical features

●Inflicted head injury (Shaken baby syndrome) is the etiology of SDH in the majority of infants and young children ≤2 years of age. In these patients, the history frequently omits mention of trauma and is often misleading. (See 'History' above.)

●Children ≤2 years of age with inflicted head injury and SDH demonstrate nonspecific clinical signs of brain injury and may also have associated features of physical abuse (eg, retinal hemorrhage, skull and/or skeletal fractures). (See 'Abusive head injury (shaken baby syndrome)' above.)

●A history of major head trauma (eg, motor vehicle collision) is usually found in children with SDH caused by unintentional head injury. Predisposing factors (eg, bleeding tendency, cerebral atrophy, arachnoid cyst) may rarely account for the development of SDH in children with a history of minor head injury. (See 'History' above.)

●An SDH should be suspected if there is a witnessed deterioration in neurologic status after a head injury. (See 'History' above.)

●Lateralizing neurologic signs (eg, anisocoria, hemiparesis, hemiplegia) arise from compression of the third cranial nerve and brainstem. These are indicators of progression to cerebral uncal herniation. (See 'Unintentional injury' above.)

Primary evaluation and management

●The order of priority in the initial assessment and treatment of the injured child suspected with possible SDH is the same as for any trauma patient (table 4). A rapid neurologic examination should focus on mental status using an age appropriate GCS (table 3), pupillary findings, cranial nerves, and motor function. (See 'Initial assessment and treatment' above and "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

●Any child with a GCS ≤12 (table 3) warrants emergent consultation and evaluation by a neurosurgeon. Children with a GCS ≤8 should undergo ICP monitoring. (See 'Neurosurgical consultation' above.)

●Head CT is the mainstay of diagnostic imaging because of the speed with which it can be obtained and interpreted, and its ability to demarcate in detail the extent of the hemorrhage for surgical planning and its superior detection of skull fractures. In some centers, rapid MRI is becoming the preferred imaging modality for children to reduce radiation exposure. (See 'Radiographic imaging' above.)

●Diagnosis of a SDH in a child with no plausible mechanism of injury should prompt involvement of an experienced child protection team (eg, social worker, nurse, physician with more extensive experience in the management of child abuse), if available. In many parts of the world (including the United States, United Kingdom, and Australia), a mandatory report to appropriate governmental authorities is also required. (See 'Child protection' above.)

Definitive management

●The decision to perform surgery on children with SDH is based upon physical findings and results of brain imaging; no clear criteria exist. We recommend that most children with acute SDH, neurologic impairment, and midline shift on imaging undergo surgical evacuation (Grade 1C). Frequently children who are comatose with severe brain swelling and signs of infarct on imaging are not good candidates for surgical evacuation of a SDH. This approach contrasts sharply with management of epidural hematoma in children where urgent surgery is always indicated in the presence of significant neurologic compromise. (See 'Operative decision' above and 'Temporizing procedures' above and 'Nonoperative management' above and "Intracranial epidural hematoma in children".)

●If at all possible, the decision to manage SDH nonoperatively should be made in conjunction with a neurosurgeon. In instances where neurosurgery is not physically available to the managing physician and transport to a higher level of care poses risk to the patient, phone consultation and remote review of the brain imaging by a neurosurgeon may assist in guiding proper patient disposition and care. (See 'Nonoperative management' above.)

●Children with SDH who are initially managed nonoperatively should be admitted to the hospital and observed in a facility where experienced pediatric trained personnel can monitor for neurologic changes. Patients with GCS ≤8 should have continuous monitoring of ICP during observation. In addition, 24 hour emergency access to brain imaging and a properly equipped operating room are essential, as deterioration can occur at any time. A repeat brain scan at 24 hours or sooner, depending on clinical status, guides further surgical management. (See 'Nonoperative management' above.)

●The child's neurologic status on presentation best predicts the outcome after a SDH regardless of age or mechanism of injury. (See 'Outcome' above.)