A 2-month-old previously healthy male infant was brought in by his mother after a seizure. She noted that he had seemed irritable and was not feeding well several hours prior to the seizure. She denied any trauma or fever. On examination, retinal hemorrhages were noted, but there were no other signs of trauma, and no signs of infection. The child was irritable, lethargic, and had poor tone. An emergent non-contrast CT was obtained and demonstrated a subdural hematoma (Figure 203-1). Neurosurgery was consulted and the infant underwent emergency craniectomy and evacuation of the subdural hematoma (Figure 203-2). An evaluation for child abuse was initiated.

Subdural hematomas (SHs) can occur at any age, but are most common in infants. Most SHs are caused by trauma. Symptoms are generally nonspecific such as irritability or poor feeding in infants and confusion or headaches in older children. Treatment is prompt consultation with a neurosurgeon.

• 
  

  SHs occur at all ages.

  
  
• 
  

  Eight percent of asymptomatic newborns can have an SH.¹

  
  
• 
  

  Twenty-four of 100,000 infants ages 0 to 1 year in United Kingdom population studies.²

  
  
• 
  

  Mortality rate of traumatic SH in treated children ages 0 to 17 is approximately 22 percent.³

• 
  

  Most SHs are caused by trauma, either accidental or intentional, from a direct injury to the head or shaking injury in an infant.

  
  
• 
  

  Nonaccidental trauma, falls, and motor vehicle accidents are the most common causes of traumatic SH.

  
  
• 
  

  SHs can occur during a nontraumatic birth.

  
  
• 
  

  Motion of the brain within the skull causes a shearing force to the cortical surface and interhemispheric bridging veins.²

  
  
• 
  

  This force tears the weakest bridging veins as they cross the subdural space, resulting in an acute SH as seen in Figure 203-1.²

  
  
• 
  

  Three days to 3 weeks after the injury, the body breaks down the blood in an SH; water is drawn into the collection causing hemodilution, which appears less white and more gray on noncontrast CT.²

  
  
• 
  

  If the hematoma fails to resolve, the collection has an even higher content of water and appears darker on a noncontrast CT; it may have fresh bleeding or may calcify (chronic SH).² This is often of the same color as brain parenchyma on noncontrast CT.

  
  
• 
  

  Nontraumatic causes reported in the literature include spontaneous bleeding because of bleeding disorders or anticoagulation, meningitis, and complications of neurologic procedures, including spinal anesthesia.

Poor prognosis is seen in children with:⁴