Intracranial Hemorrhage Overview

Introduction

• Intracranial hemorrhage (ICH) is a life-threatening emergency, where bleeding within the skull increases intracranial pressure, potentially damaging the brain and leading to permanent neurological deficits or death.

Four Categories of ICH

• ICH is categorized into four types: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage.
• Intracranial hemorrhage refers to any bleeding within the skull.
• Intracerebral hemorrhage specifically refers to bleeding within the brain parenchyma.
• Common presenting symptoms include headache, nausea, vomiting, confusion, somnolence, or seizure.
• Patients can present with a wide spectrum of symptoms, ranging from alert and conversant to moribund.
• Minor head trauma can lead to devastating intracranial bleeding, especially in elderly, alcoholic, or anticoagulated patients.

Subarachnoid Hemorrhage (SAH)

• The classic symptom of SAH is an acute onset "thunderclap" headache reaching maximum intensity within seconds, often accompanied by loss of consciousness, vomiting, neck stiffness, or seizure.
• The headache is often located at the back of the head (occipital).
• Sentinel headache is a warning headache that precedes a larger, catastrophic bleed.
• Hunt and Hess Grading System classifies SAH severity based on clinical presentation.
• Risk factors for SAH include: recent exertion, hypertension, excessive alcohol consumption, sympathomimetic use, cigarette smoking, and family history.
• Most SAH is caused by the rupture of saccular aneurysms.

Epidural Hematomas (EDH)

• EDH is the accumulation of blood between the skull and the dura, usually occurring after significant blunt head trauma.
• Fractures of the temporal bone can disrupt the middle meningeal artery, leading to high-pressure bleeding within the cranial vault.
• Initial actions and primary survey:
  • ABCD's: Airway, breathing, circulation, and disability.
  • Neuroprotective rapid-sequence intubation protocol is preferred for intubation.
  • Pre-intubation neurological exam should document Glasgow Coma Score (GCS), pupillary size and reactivity, and motor strength.
  • Cushing's triad (hypertension, bradycardia, abnormal respiratory patterns) is a sign of rapidly increasing intracranial pressure and imminent brain herniation.
  • Other herniation signs include lack of pupillary reaction and pupillary asymmetry.

Diagnostic Testing

• CT scan: The mainstay of diagnosis in ICH.
  • Acute bleeding appears hyperdense (whiter) on CT.
  • Subacute phase (days 3-14) blood appears isodense (same shade of grey) to brain parenchyma.
  • Chronic phase (after two weeks) blood appears hypodense (darker) relative to the brain.
  • Increased intracranial pressure can be identified on CT by midline shift, ventricular compression, obliteration of sulci, and blurring of the grey-white junction.

Treatment

• Medical treatment:

  • Assess and reassess ABCD's.
  • Discontinue or reverse anticoagulation.
  • Prevent hypotension and hypoxemia.
  • Control ICP.
  • Prevent seizure: prophylaxis may be necessary.
  • Treat fever and infection aggressively.
  • Control blood glucose (target 140-185 mg/dL).
  • ICP control strategies: monitoring/lowering blood pressure, head elevation (30 degrees), sedation and analgesia, mannitol, mild hyperventilation.

• Surgical treatment:

  • Timely neurosurgical consultation is crucial for patients with intracranial hemorrhage.

Disposition

• Most patients with ICH require close observation in an intensive care unit or neurosurgical ward.
• Physiotherapy and occupational therapy are often required before discharge.

Pearls and Pitfalls

• Many patients present with headache, but only a small percentage have a serious intracranial hemorrhage.