Updated: 6/26/2017

Intracranial Hemorrhage

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Snapshot
  • A 51-year-old man presents to the emergency department due to headache, nausea, and pupillary abnormalities after a physical altercation. The patient was in his usual state of health until there was a fight that resulted in head trauma. Medical history is significant for hypertension and chronic alcohol abuse disorder of over 15 years, which is treated with hydrochlorothiazide and disulfiram. His blood alcohol level is 0.32%. On physical examination, the patient appears confused and a dilated pupil that is unresponsive to light. A non-contrast head CT is shown. (Acute subdural hematoma)
Introduction

 

Intracranial Hemorrhage
Type Pathogenesis Presentation and Management Head CT
Epidural hematoma 

  • Typically secondary to rupture of the
       
    • middle meningeal artery  in the setting of
      • fracture of the temporal bone (pterion)
  • Recall that the middle meningeal artery is a branch off of the
    • maxillary artery 
  • Initially there may be no symptoms (lucid interval
  • As the hematoma grows, it
    • leads to brain tissue compression which
      • increases intracranial pressure
  • This increased intracranial pressure can result in
    • brain herniation such as
      • transtentorial herniation 
  • Management
    • craniotomy and hematoma evacuation when indicated
  • Lens-shaped biconvex hematoma secondary to 
    • a rapidly expanding hematoma that peels the dura away from the skull
      • recall that this is due to being under arterial pressure
Subdural hematoma 
  • Secondary to rupture of the
    • bridging veins
  • The most common cause is
    • head trauma (e.g., falls, assaults, and motor vehicle accidents)
  • Risk factors
    • significant cerebral atrophy, such as in
      • the elderly
      • chronic alcohol abuse
      • previous traumatic brain injury
  • Clinical presentation depends on if it is a
    • chronic subdural hematoma
    • acute subdural hematoma
  • Chronic subdural hematoma
    • typically seen in the elderly
    • can be seen with minimal or absent history of head trauma
    • vague symptoms such as
      • headache
      • cognitive impairment
      • unsteady gait
      • the focal accumulation of blood can result in
        • focal seizures
        • focal neurologic deficits
  • Acute subdural hematoma
    • typically has a history of traumatic injury
    • symptoms of increased intracranial pressure such as
      • headache
      • vomiting
      • cranial nerve palsies
  • Management
    • surgical removal (e.g., craniotomy or burr hole)
  • Blood accumulates between the dura and the arachnoid which creates
    • crescent shaped hematoma 
Subarachnoid hemorrhage
  • Most commonly due to 
    • arterial aneurysm rupture in the subarachnoid space, which can result from
      • traumatic causes 
      • non-traumatic causes (spontaneous rupture)
  • Less commonly due to
    • arteriovenous malformation
  • Risk factors
    • atherosclerotic disease
    • smoking
    • excessive alcohol intake
    • polycystic kidney disease
    • Ehlers-Danlos syndrome
    • fibromuscular dysplasia
  • Sudden "thunderclap" headache or
    • "the worst headache of my life"
  • Meningeal irritation
    • photophobia
    • nuchal rigidity
  • Can also result in
    • focal neurologic deficits
    • impaired conciousness
    • coma
  • Management
    • evaluate all cerebral vessels for aneurysm location
      • (e.g., angiogram)
    • oral or via nasograstric tube nimodipine should be administered to 
      • prevent cerebral vasospasm 
        • however, it does not angiographically improve vasospasm
      • improve outcomes
    • surgical clipping or
      • endovascular coiling
  • Blood accumulates within the subarachnoid space, where 
    • the major blood vessels of the brain are housed
  • Blood can be found around the sulci and contours the pia 
  • non-contrast head CT is used and will detect blood if
    • performed within the first 3 days after aneurysm rupture
  • Note a lumbar puncture should be performed if
    • the non-contrast head CT is negative and
      • clinical suspicion for subarachnoid hemorrhage is high
Hypertensive hemorrhage
  • Secondary to 
    • uncontrolled hypertension (HTN)
      • note that HTN is a common cause of intracerebral hemorrhages
  • HTN on the small vessels can result in
    • lipohyalinosis
    • Charcot-Bouchard microaneurysms
  • Symptoms depend on 
    • where the hemorrhage occurs
      • for example, putamenal hemorrhages can result in
        • hemiplegia
        • hemisensory loss
        • gaze palsy
        • coma
    • how large the hemorrhage is
      • if large, it can result in
        • symptoms of increased intracranial pressure
  • Management
    • involves both medical and surgical interventions
  • Hyperintense lesions can be seen on non-contrast head CT (just like in other causes of an acute bleed) in typical locations such as 
    • basal ganglia (most common)
    • thalamus
    • cerebellum
    • pons
Lobar hemorrhage
  • Can be secondary to
    • amyloid angiopathy (most common cause)
      • seen in older patients (> 50 years of age)
    • HTN
  • Amyloid can deposit in the vessel wall, making
    • it fragile and thus
      • prone to bleed
  • Symptoms depend on 
    • where the hemorrhage is such as
      • parietal lobe
      • occipital lobe
        • e.g., contralateral homonymous hemianopsia
    • how large the hemorrhage is
      • if large, it can result in
        • symptoms of increased intracranial pressure
    • these patients are at higher risk for seizures than hypertensive hemorrhages
  • Management
    • involves both medical and surgical interventions
  • Hyperdense lesion affecting a particular lobe (e.g., parietal and occipital) on non-contrast head CT 
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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