Subdural haematoma G044

Current RMA Instruments

Changes from previous Instruments

ICD Coding

• ICD-9-CM Codes: 432.1
• ICD-10-AM Codes: I62.0

Brief description

A subdural haematoma is a localised collection of blood in the space between the outer and middle layers of the lining of the brain or spinal cord (the meninges).  It may be an acute or chronic condition. 

Confirming the diagnosis

DIagnosis typically requires neuroimaging (CT scan or MRI). 

The relevant medical specialist is a neurologist or neurosurgeon.

Additional diagnoses that may be covered by SOP

• Nil

Conditions not covered by SOP

• Epidural haemorrhage^#
• Intracerebral haemorrhage* - cerebrovascular accident SOP
• Subarachnoid haemorrhage*
• Subdural haematoma due to extension of bleeding into subdural space from a cerebral tumour - code to underlying tumour
• Subdural haematoma that is an extension from an intracerebral haemorrhage* - cerebrovascular accident SOP

* another SOP applies

^# non-SOP condition

Clinical onset

In the majority of cases there will be a preceeding head trauma.  The head trauma may be minor in people with other risk factors.  With acute subdural haematoma there will be either immediate loss of consciousness or a delayed neurological decline within two days of the trauma.  With chronic subdural haematoma neurological symptoms may not become apparent until weeks after the trauma.

Clinical worsening

Treatment varies depending on presentation.  The condition varies from being a neurological emergency requiring immediate surgery and having a high fatality rate, to a stable condition that can be managed conservatively.   Worsening is unlikely but may be evidenced by a new accumulation of blood at the site of an earlier bleed.