Intracranial Hemorrhage Overview

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Questions and Answers

What is the classic presenting symptom of subarachnoid hemorrhage (SAH)?

Gradual headache over several days

Intermittent migraines

Acute onset 'thunderclap' headache (correct)

Dull, throbbing headache

Which grading system is used to classify the severity of subarachnoid hemorrhage?

Newcastle Scale

Hunt and Hess Grading System (correct)

Glasgow Coma Scale

Modified Rankin Scale

What percentage of patients with subarachnoid hemorrhage may experience a warning headache prior to the event?

15-20%

30-50% (correct)

70-80%

5-10%

Which of the following is considered the strongest risk factor for subarachnoid hemorrhage?

Family history Signup and view all the answers

In the context of epidural hematomas, what typically leads to the risk of bleeding?

Fracture of the temporal bone Signup and view all the answers

What kind of headache is often associated with subarachnoid hemorrhage and reaches maximum intensity within seconds?

Thunderclap headache Signup and view all the answers

Which of the following is NOT a risk factor for subarachnoid hemorrhage?

Low carbohydrate diet Signup and view all the answers

What is the term used for a small bleed that may precede a larger subarachnoid hemorrhage?

Warning headache Signup and view all the answers

What is the main danger of intracranial hemorrhage?

Increased intracranial pressure Signup and view all the answers

Which of the following is not a type of intracranial hemorrhage?

Interlaminar hemorrhage Signup and view all the answers

Which of the following symptoms is NOT commonly associated with intracranial hemorrhage?

Rash Signup and view all the answers

What is the difference between intracranial hemorrhage and intracerebral hemorrhage?

Intracranial hemorrhage refers to more generalized bleeding within the skull. Signup and view all the answers

What demographic is at higher risk of devastating intracranial bleeding from minor trauma?

Elderly individuals Signup and view all the answers

When managing a patient with a deteriorating level of consciousness, which step should be prioritized?

Assessing airway and breathing Signup and view all the answers

Which imaging technique is vital in identifying types of intracranial hemorrhage?

Computed Tomography (CT) Signup and view all the answers

What indicates a possible subarachnoid hemorrhage when interpreting lumbar puncture results?

Xanthochromia in cerebrospinal fluid Signup and view all the answers

What appearance does subdural hematoma typically have on imaging?

Crescent-shaped Signup and view all the answers

Why might intracranial bleeding be easily missed during the initial phase?

Blood and brain may appear the same shade of grey Signup and view all the answers

What change occurs to the appearance of blood on CT after about two weeks?

It appears hypodense relative to the brain Signup and view all the answers

What is a potential radiologic sign of increased intracranial pressure?

Obliteration of the sulci Signup and view all the answers

What is the recommended action if a CT scan is normal within the first 6 hours after SAH symptoms begin?

Consider LP unnecessary Signup and view all the answers

What is the typical sensitivity range of CT scans for detecting SAH within the first 6 hours?

99-100% Signup and view all the answers

What might indicate the presence of subarachnoid hemorrhage on a CT scan?

Blood in the ventricles and sulci Signup and view all the answers

How can the experience of the reader affect the sensitivity of a CT scan?

Reader experience can influence diagnostic accuracy Signup and view all the answers

What should be prioritized when assessing a patient with potential intracranial hemorrhage?

Secure the airway Signup and view all the answers

What does Cushing’s triad indicate?

Imminent brain herniation Signup and view all the answers

Which of the following is NOT a feature of Cushing’s triad?

Hypotension Signup and view all the answers

What is the primary diagnostic tool for identifying intracranial hemorrhage?

Head CT scan Signup and view all the answers

What occurs in the subacute phase of intracranial hemorrhage?

Blood becomes isodense to the brain tissue Signup and view all the answers

What should be monitored during the initial assessment of a patient with a suspected intracranial hemorrhage?

Pupillary reaction and motor strength Signup and view all the answers

What is a neurological exam's role prior to intubation?

To help determine prognosis Signup and view all the answers

Which sign indicates imminent herniation in a patient with intracranial hemorrhage?

Pupillary asymmetry Signup and view all the answers

What should be monitored or managed to control intracranial pressure (ICP)?

Elevating the head of the bed to 30 degrees Signup and view all the answers

Which patient situations would make the application of certain rules for trauma inappropriate?

Coumadin use in absence of trauma Signup and view all the answers

Which of the following is NOT a tenet to apply in managing patients with intracranial hemorrhage?

Encourage physical activity immediately Signup and view all the answers

What is a dangerous mechanism of injury that indicates a higher risk for intracranial hemorrhage?

Pedestrian struck by vehicle Signup and view all the answers

What is an appropriate course of action if signs of rapidly rising ICP are observed?

Consider mannitol or mild hyperventilation Signup and view all the answers

What is crucial for patients with intracranial hemorrhage before hospital discharge?

Receiving intensive physiotherapy and occupational therapy Signup and view all the answers

What should be aggressively treated alongside intracranial hemorrhage management?

Fever and infection Signup and view all the answers

When should the closure of anticoagulation treatment be considered in patients with intracranial hemorrhage?

In all trauma cases Signup and view all the answers

Study Notes

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.

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Description

Explore the critical topic of intracranial hemorrhage (ICH), a life-threatening emergency involving bleeding within the skull. This quiz covers the four categories of ICH, including symptoms, causes, and specific conditions like subarachnoid hemorrhage. Prepare to deepen your understanding of this medical emergency.