CURRENT TRENDS IN MANAGING
SUBDURAL HEMATOMA INJURIES
When is it Safe to Return to Contact Sports?
Jamie Adams, MEd, ATC, CES
Carolyn Dartt, MEd, ATC
Ilona Barash, MD, PHD
Objectives
• Distinguish between different types of meningeal injuries in
the brain
• Discuss how subdural hematomas (SDH) effect contact
athletes
• Review and discuss current guidelines for return to play
after SDH
ANATOMY
The Brain
• Made up of 4 gelatinous lobes
floating in cerebrospinal fluid (CSF)
within the skull
• Vascularized by the internal carotid
and vertebral arteries, the internal
jugular vein, the cerebral veins,
external veins, basal vein, terminal
vein, choroid vein and the cerebellar
veins
• The brain is covered by 3 meninges:
• dura mater
• arachnoid
• pia mater
From Left to Right:
• Scalp
• Periosteum
• Skull
• Dura Mater
• Arachnoid
• Pia Mater
Dura Mater
• Most superficial of the 3 meninges
• Is a thick durable sac-like membrane consisting of large blood vessels
• It is a fairly loose membrane comprised of dense fibrous tissues
Arachnoid
• Middle of the 3 meninges
• Is named because of it's spider web-like appearance
• Thin, transparent membrane
• Considered important in the blood brain barrier
Pia Mater
• Deepest of the 3 meninges
• In direct contact with the brain tissue and supplies the brain with nourishment
through its capillaries
• Very thin delicate tissue that follows all the contours of the brain
4 Types of Injuries Involving Bleeding
Within the Skull
• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid Hemorrhage
• Intracerebral Hemorrhage
Intracerebral Hemorrhage
• Bleeding in one or more of the
lobes
• Usually seen in traffic accidents
or falls
• Data have shown that traumatic
intracerebral hemorrhages
often expand over time
• S&S often mimic stroke
symptoms
Subarachnoid Hemorrhage
• Defined as bleeding between
the arachnoid and pia mater
membranes
• Can happen spontaneously
from an aneurysm rupture or
from trauma
• Symptoms include "thunderclap
headache", loss of
consciousness, vomiting and
possibly seizures
Epidural Hematoma
• Is a collection of blood between
the skull and the dura mater
• ~15-20% are fatal
• Most common cause is trauma;
usually acceleration/
deceleration or transverse
forces
• Trauma causes tears to the
arteries within the dura mater
• Hematoma reaches maximum
at ~6-8 hours after injury
Epidural Hematoma S&S
• Brief lucid period
• Headache
• Unconsciousness
• Abnormal posturing
• Abnormal pupil reactions
• Weakness of the extremities on the opposite side from injury
Subdural Hematoma
• defined as a collection of blood
between the dura mater and the
arachnoid membrane
• these injuries are usually
associated with a traumatic brain
injury (TBI); most often from
shearing forces
• results from injuring veins bridging
between the dura mater and the
other meninges
• Signs and Symptoms (S&S) are
often delayed because veins
bleed slower than arteries
Subdural Hematoma S&S
• A history of recent head injury
• Loss of consciousness or fluctuating
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levels of consciousness
Irritability
Seizures
Pain
Loss of muscle control
Altered breathing patterns
Hearing loss or hearing ringing
(tinnitus)
Ataxia, or difficulty walking
Blurred vision
Deviated gaze, or abnormal
movements
• Numbness
• Headache (either constant or
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fluctuating)
Dizziness
Disorientation
Amnesia
Weakness or lethargy
Nausea or vomiting
Loss of appetite
Personality changes
Inability to speak or slurred speech
Management of Intracranial Hematomas
• Epidural
• Surgical
• Thickness >30 cm3 regardless of the
patient's GCS
• Conservative
• in patients with a GCS score greater
than 8 without focal deficit
• <30 cm3 thick
• <15 mm thickness
• <5 mm midline shift (MLS)
• can be managed non-operatively with
serial CT scanning and close
neurological observation
• Subarachnoid
• Surgical
• Rarely done in isolated traumatic
SAH
• If evaluation for underlying aneurysm
is positive, this will often be treated
• Conservative
• In patients with a GCS score in the
range of 13-15
• Monitoring with follow up scans to
make sure bleeding is resolving
• Monitor ICP and BP levels
Management of Intracranial Hematomas
• Subdural
• Surgical
• Thickness >10mm
• Midline shift >5mm
• If GCS score decreases 2+ points
between injury and hospital admission
• Asymmetric or fixed dilated pupils
• ICP > 20 mmHg
• Burr holes or craniotomy are the
surgical procedures
• Conservative
• If GCS >9, monitor ICP
• Small, no mass effect on CT
• Risk of changing to chronic SDH
• Reevaluate if neuro deterioration
• If neuro deterioration occurs, repeat CT
scans are indicated
CASE STUDY
CASE REPORT
•
18 y/o MLAX athlete fell while
skateboarding
• Presented to ED with closed head
injury
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8 mm SDH and small focal SAH
No acute cervical spine injury
No skull fracture
Athlete has no memory of fall
• No previous history of
concussions/TBI
27 Sep 2012
27 Sep 2012 • Initial Injury
Oct 2012
• Last visit with personal
neurosurgeon
1 Nov 2012 • Lacrosse PPE
1 Jan 2013
• Cleared to RTP by personal
neurosurgeon
• Initial visit with UCSD
17 Jan 2013 team physicians
• Follow up
22 Jan 2013 MRI
7 Feb 2013 • RTP
22 Jan 2013
Case Report
• Treatment
• Rest
• Personal neurosurgeon recommended no RTP as
safest decision
• If RTP is desired, at least 12 week waiting period with
no high risk activities (non-contact drills/workouts ok)
• Recommended waiting as long as possible to return to
lacrosse
• Team physicians and personal physicians discussed
need for f/u MRI before clearance
• MRI on 22 Jan 2013 showed that the SDH had
resolved
• Full RTP clearance as of 7 Feb 2013
• No further s/s since RTP
Uniqueness
• No clear current guidelines on return to contact sports after a subdural
hematoma
• Most relevant research was from around 1998
• This research recommended no RTP for at least 1 year
• Discussion with several physicians of different specialties provided many
different opinions on what was necessary to determine RTP timeline
RETURN TO PLAY DISCUSSION
Return to Play Guidelines After Head Injury
Cantu 1998:
• Conditions that contraindicate competition in contact sports
• Persistent postconcussion symptoms
• Permanent central neurologic sequelae from head injury (e.g.,
organic dementia, hemiplegia, homonymous hemianopsia)
• Hydrocephalus
• Spontaneous subarachnoid hemorrhage from any cause
• Symptomatic neurologic or pain-producing abnormalities about
the foramen magnum
Cantu 1998 continued
• No contact sports if operative intervention was required:
• Concern about prolonged scarring of the pia-arachnoid
• Loss of the normal cushioning effect of the CSF
• “return to a collision sport may be permitted in selected cases 1
year or more after the injury if neurologic recovery is complete.
Again, extreme deliberation and informed discussions with the
athlete and his family is urged.”
1 Year Guideline
• Davis et al 2010:
• 31 yr. old boxer with SDH
• No surgical intervention
• Imaging included MRI/MRV/MRA and neurologic exam normal
• Durand and Adamson 2004:
• 1 year return to play guideline
• No justifications were noted
Nagahiro and Mizobuchi 2014
• Case reports of young Judo participants who returned to
play after traumatic SDH, and had fatal recurrent SDH
afterwards
• “As most judo-related accidents happen in young
inexperienced participants, even in a small subdural
hematoma has been absorbed and neuroimaging returns
to normal findings, in principle, children and adolescents
must not be allowed to RTP.”
AMSSM List Serve Survey
Dr. Matthews Gammons: Vermont
• “No evidence based guidelines. No expert based opinion
guidelines that I have seen. We have had half a dozen
over the last 5 years. All were out at least 3 months and
had resolution (except hemosiderin) on imaging and
normal neuro. Current thinking is this does not increase
risk once resolved.”
AMSSM List Serve Survey
Dr. Jeffrey Radakovich: Washington
• “I had an incoming freshman football player with a similar history
who was asymptomatic with an essentially normal MRI by the
time I saw him for a PPE. After discussions with several head
injury experts including Dr. Cantu, we cleared him. The main
issue was being sure there were no underlying structural issue
that predisposed him to bleed such as an AVM. Prior to coming
to see me he had had an MRA and I believe even a MR
venogram. Would be worth considering MRA or does your
radiologist feel confident that a vascular abnormality can be
excluded with the MR?”
AMSSM List Serve Survey
Dr. Jennifer King: Hawaii
• “I had a similar case, could not find guidelines, but
discussed with colleagues and neurosurgeons; basic
consensus was that as long as asymptomatic and bleed
resolving, can RTP after 6 weeks from injury; both my
kids did well.”
Recommendations For Return to Play After
Non-Operative Major Head Injury
• A completely normal neurological exam
• Advanced imaging after the event:
• MRI: must be normal or perhaps only has some residual
hemosiderin
• Consider MRA/MRV
• Must exclude any underlying predisposing factors for the initial
bleed
Recommendations For Return to Play After
Non-Operative Major Head Injury
• Informed Consent:
• Long, involved discussion with the patient and family about all risks, benefits
and alternatives
• Time Frame? Unclear.
• To be safe and within published guidelines, 1 year
• General consensus seems to be sooner than that
• Gradual Return to Play
• Close monitoring of the athlete:
• Concussion symptoms
• Neurologic symptoms
• Extra attention made to any repeat head injury
Recommendations For Return to Play After
Non-Operative Major Head Injury
If there is any question about what to do, consult another
specialist and get a second or third opinion:
• Neurosurgeons
• Neurologists
• Primary Care Sports Medicine Specialists
Our Case Conclusion
• Cleared for play
• Did great
• No adverse outcomes
(yet)
• >2 years out
• He and his family were
excited to keep playing
References
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• 1.
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Garg RK, MD, Levine SR, MD. Traumatic intracerebral hemorrhage. Medlink Neurology. 2014.
http://www.medlink.com/medlinkcontent.asp?page=home.
2.
Bullock MR, MD, PhD., Chestnut R, MD, Ghajar J, MD, PhD., et al. Surgical Management of Acute Subdural
Hematomas. Neurosurgery. March 2006 2006;58(3):S2-15-S12-24.
3.
Ahmed E, Aurangzeb A, Khan S, et al. Frequency of conservatively managed traumatic acute subdural haematoma
changing into chronic subdural haematoma. J Ayub Med Coll Abbottabad. Jan-Mar 2012 2012;24(1):71-74.
4.
Phelan HA, Richter AA, Scott WW, et al. Does isolated traumatic subarachnoid hemorrhage merit a lower intensity
level of observation than other traumatic brain injury? Journal of Neurotrauma. October 15, 2014 2014;31(20):1733-1736.
5.
Cantu R. Return to play guidelines after a head injury. Clinical Journal of Sport Medicine. January 1998
1998;17(1):45-60.
6.
Davis G, Marion D, Le Roux P, Laws E, McCrory P. Clinics in neurology and neurosurgery- extradural and subdural
haematoma. Br J Sports Med. December 2010 2010;44(16):1139-1143.
7.
Durand P J, Adamson G. On-the-field management of athletic head injuries. J Am Acad Orthop Surg. 2004 May-Jun
2004;12(3):191-195.
8.
Giza C, Kutcher J, Ashwal S, et al. Summary of evidenc-based guideline update: evaluation and management of
concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology.
2013 Jun 11 2013;80(24):2250-2257.
9.
Harmon K, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement:
concussion in sport. Br J Sports Med. 2013 Jan 2013;47(1):15-26.