Intracranial Hemorrhage

Question 1

What are the 4 broad categories of Intracranial Hemorrhages?

Answer 1

Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intracerebral hemorrhage

Question 2

What is the difference between an intracerebral hemorrhage and an intracranial hemorrhage?

Answer 2

Intracerebral is bleeding within the brain parenchyma. Intracranial hemorrhage is bleeding within the brain cavity in general.

Question 3

Common symptoms of intracranial hemorrhages

Answer 3

headache, nausea, vomiting, confusion, somnolence, or seizure.

Question 4

Subarachnoid hemorrhage Symptoms

Answer 4

• Acute onset “thunderclap” headache. Reaches maximum intensity within seconds. Usually Occipital.
• Loss of consciousness, vomiting, neck stiffness, or seizure
• (30-50%) will also have a warning (sentinel) headache

Question 5

Hunt and Hess Grading System for Subarachnoid hemorrhage

Answer 5

Grade 1: Asymptomatic, mild headache, slight nuchal rigidity
Grade 2: Moderate to severe headache, nuchal rigidity , no neurologic deficit other than cranial nerve palsy
Grade 3: Drowsiness / confusion, mild focal neurologic deficit
Grade 4: Stupor, moderate-severe hemiparesis
Grade 5: Coma, decerebrate posturing

Question 6

What are risk factors for Subarachnoid hemorrhages including which is the strongest risk factor?

Answer 6

Recent exertion, hypertension, excessive alcohol consumption, sympathomimetic use, and cigarette smoking are risk factors for both SAH and intracerebral bleeds. However, the strongest risk factor for SAH is family history, which carries a 3 – 5 fold risk.

Question 7

What is the source of most Subarachnoid hemorrhages?

Answer 7

Most SAH is due to the rupture of saccular aneurysms

Question 8

Epidural hematoma etiology

Answer 8

Accumulations of blood between the skull and the dura, and typically occur after significant blunt head trauma.

Question 9

What is the most common artery injury in an epidural hematoma?

Answer 9

Fractures of the temporal bone can disrupt the middle meningeal artery, leading to high-pressure bleeding within the cranial vault.

Question 10

What is the classic description of an epidermal hematoma?

Answer 10

brief loss of consciousness after a blow to the head, followed by a lucid period. Soon after, level of consciousness deteriorates again, possibly progressing into herniation and death.

Question 11

Where does the blood pool in a subdural hematoma?

Answer 11

extra axial blood collections between the dura and the arachnoid mater.

Question 12

What blood vessels are usually injured in a subdural hematoma?

Answer 12

bridging veins are sheared during acceleration-deceleration of the head.

Question 13

Presentation of a subdural hematoma

Answer 13

Can grow fairly slowly and the presentation can be delayed by days to weeks.
Subdural hematomas have a wide clinical spectrum. Rapid accumulation of extra-axial blood, the absence of pre-existing atrophy, and the presence of other traumatic brain injuries correspond to a worse neurologic status at presentation. As the younger brain is less atrophic, even small volumes of extra-axial blood can increase ICP and result in severe deficits.

Question 14

What should you watch out for in a pediatric patient with a subdural hematoma?

Answer 14

Child Abuse or birth trauma.

Question 15

Kid with subdural hematoma. What are signs of “shaken baby syndrome?

Answer 15

‘Shaken Baby Syndrome’, including retinal hemorrhages and long bone fractures. Infants with increased ICP might present with a bulging fontanelle, enlarged head circumference, emesis, failure to thrive, and seizure.

Question 16

!!Chronic subdural hematoma are the grand imitator

Answer 16

It occurs more often in elderly and alcoholic patients as they are most prone to atrophy and/or coagulopathy. The most common presentation is altered mental state. Hemiparesis, headache, and falls are other possible features

Question 17

What should you do before intubating if patient is unconscious?

Answer 17

Check a fingerstick glucose.

Pre-intubation should include GCS, muscle strength, reflexes, and PERRLA

Question 18

What is cushion’s triad?

Answer 18

Hypertension
Bradycardia
Abnormal respiratory patterns

Question 19

What is a sign of brain herniation?

Answer 19

Blown pupil. Not reactive. Bilateral papilledema indicates increased ICP

Question 20

What does bleeding look like on head CT at different time periods?

Answer 20

• Acute bleeding appears hyperdense (whiter) relative to the surrounding tissues.
• Subacute phase occurs between days 3 and 14, when blood becomes isodense to the brain parenchyma. It is particularly easy to miss intracranial bleeding during this phase as the blood and the brain may appear the same shade of grey.
• After about two weeks, blood appears hypodense (darker) relative to the brain.

Question 21

Signs of increased intracranial pressure on CT

Answer 21

Midline shift
Ipsilateral compression of the ventricles with or without contralateral ventricular enlargement
Obliteration of the sulci
Blurring of the grey-white junction

Question 22

If there is a negative head CT and you still suspect a subarachnoid hemorrhage, then LP is often the next step. What would you look for in the CSF?

Answer 22

Absence or clearing of blood.

Xanthochromia

Question 23

What is Xanthochromia?

Answer 23

Xanthochromia refers to a yellow or pink discoloration of the supernatant once the CSF is centrifuged. It results from the breakdown of blood cells within the CSF.
- Think SAH!!!

Question 24

If LP or CT are indicative of subarachnoid hemorrhage, then do what for imaging?

Answer 24

Angiography. Digital subtraction angiography is gold standard, but not readily available usually. Then do MRA or CTA

Question 25

What are the Canadian Head CT Rules?

Answer 25

High Risk:
-GCS score < 15 at 2 hrs after injury
-Suspected open or depressed skull fracture
-Any sign of basal skull fracture*
-Vomiting (more than 2 episodes)
-Age greater than 65 years
Low Risk:
- Amnesia before impact > 30 min
- Dangerous mechanism ** (pedestrian,occupant ejected, fall from elevation)

Question 26

When are the Canadian Head CT Rules not applicable?

Answer 26

Rule Not Applicable If: Non-trauma cases, GCS < 13, Age < 16 years, Coumadin or bleeding disorder, Obvious open skull fracture

Question 27

What is the medical treatment for an intracranial hemorrhage?

Answer 27

Assess and reassess the ABCD’s
Discontinue or reverse anticoagulation
Prevent hypotension and hypoxemia
Control ICP
Prevent seizure: prophylaxis may be necessary depending on the type and extent of bleeding
Treat fever and infection aggressively
Control blood glucose (target 140-185 mg/dL)

Question 28

What is the medical treatment/prevention of elevated intracranial pressure?

Answer 28

Monitoring/lowering blood pressure in consultation with neurosurgery
Elevating the head of the bead to 30 degrees
Providing adequate sedation and analgesia
If signs of rapidly rising ICP or herniation, considering mannitol or mild hyperventilation (target CO2 around 30 mmHg)

Question 29

What about surgery?

Answer 29

In any patient with a bleed get a neurosurgery consult.

Question 30

When should you do a lumbar puncture if CT is negative or hard to tell?

Answer 30

Lumbar puncture is still an important part of management in patients whose CT scans are delayed more than 6 hours after the onset of symptoms.