Intracranial Bleeding

Question 1

Important info regarding Intracranial Bleeding

Answer 1

Localiztion: Most commonly occuri in basal ganglia( putamen) and thalamus( especially in hypertension patients). Other sites= Frontal-temporal, parietoccipital, cerebellar pontine areas.

Question 2

Etiology(Types) and causes of Intracranial Bleeding

Answer 2

A) Traumatic:
Epidural Hemorrhage: Due to rupture of middle meningeal artery. Accumultation of blood between the inner surface of the skull and dura matter.

Subdural Hemorrhage: Due to rupture of the bridging veins. Accumulation of blood between the dura mater and the arachnoid membrane).

Subarachnoid Hemorrhage: Rupture of cerebral artery . Accumulation of blood within the subarachnoid space(the space between the arachnoid membrane and the pia mater)

Intracerebral Hemorrhage: Due to rupture of small penetrating arteries that originate from basilar arteries or the anterior, middle, or posterior cerebral arteries.It occurs when there is bleeding within the brain tissue itself

B) Non-Traumatic :
Hypertension
Cerebral amyloid angiopathy
Aneurysm
Ruptured Arteriovenous Malformation (AVM)
Vasculitis
Coagulation disorders, anticoagulant use
CNS infections/ Neoplasms
Stimulants: Cocaine or amphetamines (raise blood pressure and increase the risk of hemorrhage.)

C) Idiopathic

Question 3

Pathological Effects of IIntracranial Bleeding

Answer 3

Midline Shift= Do decompressive craniotomy
Within 48 hrs : Disruption of BBB=> Vasogenic and cytotoxic edema = Neural damage and necrosis
Reduction (4-8 weeks) cystic cavity.

Question 4

Symptoms of Intracranial Bleeding

Answer 4

Worsen rapidly, mins-hrs: More severe than in ischemic stroke.
Severe headache, Nausea and vomiting,changes in consciousness or confusion.
Weakness or numbness on one side of the body.
Difficulty speaking or understanding speech.
Vision changes or double vision.
Seizures.
Neck stiffness (in cases of subarachnoid hemorrhage).

Basal ganglia= Hemiparesis, sensory loss, eye deviation (towards side of lesion)

Thalamus= Decreased conciousness, sensory loss, central hemiparesis, gate disturbance (away from lesion site)

Cerebellum= Ataxia, Diziness, Nausea

Lobar= Better prognosis (because intraventricular bleeding are rare)

Pons= Hemi/Tetra paresis, disturbed eye movements, decerebreation, disturbance of breathing, coma, and death.

Question 5

Diagnosis of Intracranial Bleeding

Answer 5

History, Neuro exam, GCS score

Non -contrast CT= Hyperdense lesion surrounded by hypodense edema

Once haemorrhage is conformed, perform LABS-CBC, coagulation parameters, blood glucose levels

Angiography( MRA, CTA) = Malformation, Vasculitis

*Poor outcome= >65 years old, large hematomas, GCS<11.

Question 6

Treatment of Intracranial Bleeding

Answer 6

ABCDE assesment

Neuroprotective measures= Normoxia, Normocapnia, Normotension, Euglycemia

Stop all antigoagulants, antiplatelets.

Fluid replacement, Intubation with hyperventilation, head elevation

Monitor Sp02

BP control( Target should be <1400mmHg) = Nifedipine Labetalol,Enalapril, Hydralazine

Monitor anticoagulant patterns :Consider VitK+ VitK -dependent coag. factors

ICP management= Mannitol, Hypertonic Saline, External Ventricular Drain, VP shunt( if hydrocephalus)

Surgical Intervention : Hematoma evaluation and craniotomy

Question 7

Complication of Intracranial Bleeding

Answer 7

Repeated haemorrhage
Vasospasms leading to cerebral iscemia
DVT
Seizures
Brain Herniation due to high ICP
Hydrocephalus
SIADH
Dysphagia ( if aspiration pneumonia)