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Updated: Mar 29 2023

Intracranial Hemorrhage

  • 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)
        • temporal bone fracture may present with hearing loss, periauricular ecchymosis, facial paralysis, hemotympanum, and/or dizziness
      • 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 consciousness
        • coma
      • Management
        • evaluate all cerebral vessels for aneurysm location
          • (e.g., angiogram)
        • oral or via nasogastric 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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