Intracranial Hemorrhage encompasses four broad types of hemorrhage: epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and intraparenchymal hemorrhage.[rx][rx][rx] Each type of hemorrhage is different concerning etiology, findings, prognosis, and outcome. This article provides a broad overview of the types of intracranial hemorrhage.
Types of Intracranial Hemorrhage
intracranial hemorrhage
Intra-axial hemorrhage
- signs and formulas
- ABC/2 (volume estimation)
- CTA spot sign
- swirl sign
- By region or type
- basal ganglia hemorrhage
- cerebellar hemorrhage
- remote cerebellar hemorrhage
- cerebral contusions
- cerebral microhemorrhage
- hemorrhagic venous infarct
- hemorrhagic transformation of an ischemic infarct
- cerebral intraparenchymal hyperattenuations post thrombectomy
- hypertensive intracranial hemorrhage
- intraventricular hemorrhage (IVH)
- jet hematoma
- lobar hemorrhage
- cerebral amyloid angiopathy
- pontine hemorrhage
- Duret hemorrhage
- Extra-axial hemorrhage
- extradural versus subdural hemorrhage
- extradural hemorrhage (EDH)
- venous extradural hemorrhage
- intralaminar dural hemorrhage
- subdural hemorrhage (SDH)
- calcified chronic subdural hemorrhage
- subarachnoid hemorrhage (SAH)
- types
- ruptured berry aneurysm
- berry aneurysm
- fusiform aneurysm
- mycotic aneurysm
- convexal subarachnoid hemorrhage
- traumatic subarachnoid hemorrhage (TSAH)
- perimesencephalic subarachnoid hemorrhage (PMSAH)
- ruptured berry aneurysm
- vasospasm following SAH
- grading systems
- Hunt and Hess grading system
- Fisher scale
- modified Fisher scale
- SDASH score
- WFNS grading system
- types
- subpial hemorrhage
Causes of Intracranial Hemorrhage
- Head trauma – Head trauma, caused by a fall, car accident, sports accident or another type of blow to the head.
- Injury is the most common cause of bleeding in the brain for those younger than age 50.
- High blood pressure – This chronic condition can, over a long period of time, weaken blood vessel walls. Untreated high blood pressure is a major preventable cause of brain hemorrhages. High blood pressure (hypertension), which can damage the blood vessel walls and cause the blood vessel to leak or burst.
- Aneurysm – This is a weakening in a blood vessel wall that swells. It can burst and bleed into the brain, leading to a stroke.
- Blood vessel abnormalities – (Arteriovenous malformations) Weaknesses in the blood vessels in and around the brain may be present at birth and diagnosed only if symptoms develop.
- Amyloid angiopathy – This is an abnormality of the blood vessel walls that sometimes occurs with aging and high blood pressure. It may cause many small, unnoticed bleeds before causing a large one.
- Blood or bleeding disorders – Hemophilia and sickle cell anemia can both contribute to decreased levels of blood platelets.
- Liver disease – This condition is associated with increased bleeding in general.
- The buildup of fatty deposits in the arteries (atherosclerosis).
- A blood clot that formed in the brain or traveled to the brain from another part of the body, which damaged the artery and caused it to leak.
- A ruptured cerebral aneurysm (a weak spot in a blood vessel wall that balloons out and bursts).
- The buildup of amyloid protein within the artery walls of the brain (cerebral amyloid angiopathy).
- A leak from abnormally formed connections between arteries and veins (arteriovenous malformation).
- Bleeding disorders or treatment with anticoagulant therapy (blood thinners).
- A brain tumor that presses on brain tissue causing bleeding.
- Smoking, heavy alcohol use, or use of illegal drugs such as cocaine.
- Conditions related to pregnancy or childbirth, including eclampsia, postpartum vasculopathy, or neonatal intraventricular hemorrhage.
- Conditions related to abnormal collagen formation in the blood vessel walls that can cause to walls to be weak, resulting in a rupture of the vessel wall.
Epidural Hematoma
An epidural hematoma can either be arterial or venous in origin. The classical arterial epidural hematoma occurs after blunt trauma to the head, typically the temporal region. They may also occur after a penetrating head injury. There is typically a skull fracture with damage to the middle meningeal artery causing arterial bleeding into the potential epidural space. Although the middle meningeal artery is the classically described artery, any meningeal artery can lead to arterial epidural hematoma.[rx]
A venous epidural hematoma occurs when there is a skull fracture, and the venous bleeding from the skull fracture fills the epidural space. Venous epidural hematomas are common in pediatric patients.
Subdural Hematoma
Subdural hemorrhage occurs when blood enters the subdural space which is anatomically the arachnoid space. Commonly subdural hemorrhage occurs after a vessel traversing between the brain and skull is stretched, broken, or torn and begins to bleed into the subdural space. These most commonly occur after a blunt head injury but may also occur after penetrating head injuries or spontaneously.[rx][rx]
Subarachnoid Hemorrhage
A subarachnoid hemorrhage is bleeding into the subarachnoid. Subarachnoid hemorrhage is divided into traumatic versus non-traumatic subarachnoid hemorrhage. A second categorization scheme divides subarachnoid hemorrhage into an aneurysmal and non-aneurysmal subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage occurs after the rupture of a cerebral aneurysm allowing for bleeding into the subarachnoid space. Non-aneurysmal subarachnoid hemorrhage is bleeding into the subarachnoid space without identifiable aneurysms. Non-aneurysmal subarachnoid hemorrhage most commonly occurs after trauma with a blunt head injury with or without penetrating trauma or sudden acceleration changes to the head.[rx]
Intraparenchymal Hemorrhage
Intraparenchymal hemorrhage is bleeding into the brain parenchyma proper. There is a wide variety of reasons due to which hemorrhage can occur including, but not limited to, hypertension, arteriovenous malformation, amyloid angiopathy, aneurysm rupture, tumor, coagulopathy, infection, vasculitis, and trauma.
Pathophysiology
Epidural Hematoma
Epidural hematomas occur when blood dissects into the potential space between the dura and inner table of the skull. Most commonly this occurs after a skull fracture (85% to 95% of cases). There can be damage to an arterial or venous vessel which allows blood to dissect into the potential epidural space resulting in the epidural hematoma. The most common vessel damaged it the middle meningeal artery underlying the temporoparietal region of the skull.
Subdural Hematoma
Subdural hematoma has multiple causes including head trauma, coagulopathy, vascular abnormality rupture, and spontaneous. Most commonly head trauma causes motion of the brain relative to the skull which can stretch and break blood vessels traversing from the brain to the skull. If the blood vessels are damaged, they bleed into the subdural space.
Subarachnoid Hemorrhage
Subarachnoid hemorrhage most commonly occurs after trauma where cortical surface vessels are injured and bleed into the subarachnoid space. Non-traumatic subarachnoid hemorrhage is most commonly due to the rupture of a cerebral aneurysm. When aneurysm ruptures, blood can flow into the subarachnoid space. Other causes of subarachnoid hemorrhage include arteriovenous malformations (AVM), use of blood thinners, trauma, or idiopathic causes.
Intraparenchymal Hemorrhage
Non-traumatic intraparenchymal hemorrhage most often occurs secondary to hypertensive damage to cerebral blood vessels which eventually burst and bleed into the brain. Other causes include rupture of an arteriovenous malformation, rupture of an aneurysm, arteriopathy, tumor, infection, or venous outflow obstruction. Penetrating and non-penetrating trauma may also cause intraparenchymal hemorrhage.
Symptoms of Intracranial Hemorrhage
Symptoms of a brain hemorrhage depend on the area of the brain involved. In general, symptoms of brain bleeds can include:
- Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body.
- Headache. (Sudden, severe “thunderclap” headache occurs with subarachnoid hemorrhage.)
- Nausea and vomiting.
- Confusion.
- Dizziness.
- Seizures.
- Increasing headache
- A sudden severe headache
- Seizures with no previous history of seizures
- Weakness in an arm or leg
- Decreased alertness; lethargy
- Changes in vision
- Tingling or numbness
- Difficulty speaking or understanding speech
- Difficulty swallowing
- Difficulty writing or reading
- Loss of fine motor skills, such as hand tremors
- Loss of coordination
- Loss of balance
- An abnormal sense of taste
- Drowsiness and progressive loss of consciousness
- Unequal pupil size
- Slurred speech
- Loss of balance or coordination.
- Stiff neck and sensitivity to light.
- Abnormal or slurred speech.
- Difficulty reading, writing or understanding speech.
- Change in level of consciousness or alertness, lack of energy, sleepiness or coma.
- Trouble breathing and abnormal heart rate (if the bleed is located in the brainstem).
Diagnosis of Intracranial Hemorrhage
Epidural Hematoma
Patients with epidural hematoma report a history of a focal head injury such as blunt trauma from a hammer or baseball bat, fall, or motor vehicle collision. The classic presentation of an epidural hematoma is a loss of consciousness after the injury, followed by a lucid interval then neurologic deterioration. This classic presentation only occurs in less than 20% of patients. Other symptoms that are common include severe headache, nausea, vomiting, lethargy, and seizure.
Subdural Hematoma
A history of either major or minor head injury can often be found in cases of subdural hematoma. In older patients, a subdural hematoma can occur after trivial head injuries including bumping of the head on a cabinet or running into a door or wall. An acute subdural can present with recent trauma, headache, nausea, vomiting, altered mental status, seizure, and/or lethargy. A chronic subdural hematoma can present with a headache, nausea, vomiting, confusion, decreased consciousness, lethargy, motor deficits, aphasia, seizure, or personality changes. A physical exam may demonstrate a focal motor deficit, neurologic deficits, lethargy, or altered consciousness.
Subarachnoid Hemorrhage
A thunderclap headache (sudden severe headache or worst headache of life) is the classic presentation of subarachnoid hemorrhage. Other symptoms include dizziness, nausea, vomiting, diplopia, seizures, loss of consciousness, or nuchal rigidity. Physical exam findings may include focal neurologic deficits, cranial nerve palsies, nuchal rigidity, or decreased or altered consciousness.
Intraparenchymal Hemorrhage
Non-traumatic intraparenchymal hemorrhages typically present with a history of sudden onset of stroke symptoms including a headache, nausea, vomiting, focal neurologic deficits, lethargy, weakness, slurred speech, syncope, vertigo, or changes in sensation.
Epidural Hematoma
Initial evaluation includes airway, breathing, and circulation as patients can rapidly deteriorate and require intubation. A detailed neurologic examination helps identify neurologic deficits. With increasing intracranial pressure there may be a Cushing response (hypertension, bradycardia, and bradypnea). Emergent CT head without contrast is the imaging choice of the test due to its high sensitivity and specificity for identifying significant epidural hematomas. Historically cerebral angiography could identify the shift in cerebral blood vessels, but cerebral angiography has been supplanted by CT imaging.[rx][rx][rx]
Laboratory studies should also be considered including a complete blood count to check for thrombocytopenia, coagulation studies (PTT, PT/INR) to check for coagulopathy and basic metabolic panel to check for electrolyte abnormalities.
Subdural Hematoma
After ensuring the medical stability of the patient, a detailed neurologic exam can help identify any specific neurologic deficits. Most commonly a computed tomography (CT) scan of the head without contrast is the first imaging test of choice. An acute subdural hematoma is typically hyperdense with chronic subdural being hypodense. A subacute subdural may be isodense to the brain and more difficult to identify.
Laboratory studies should also be considered including a complete blood count to check for thrombocytopenia, coagulation studies (PTT, PT/INR) to check for coagulopathy and basic metabolic panel to check for electrolyte abnormalities.
Subarachnoid Hemorrhage
Initial evaluation includes assessing and stabilizing the airway, breathing, and circulation (ABCs). Patients with subarachnoid hemorrhage can rapidly deteriorate and may need emergent intubation. A thorough neurologic examination can help identify any neurologic deficits.
The initial imaging for patients with subarachnoid hemorrhage is computed tomography (CT) head without contrast. If the patient is given contrast, this can obscure the subarachnoid hemorrhage. Acute subarachnoid hemorrhage is typically hyperdense on CT imaging. If the CT head is negative and there is still strong suspicion for subarachnoid hemorrhage a lumbar puncture should be considered. The results of the lumbar puncture may show xanthochromia. A lumbar puncture performed before 6 hours of the subarachnoid hemorrhage may fail to show xanthochromia. Additionally, lumbar puncture results may be confounded if a traumatic tap is encountered.
Identifying the cause of non-traumatic subarachnoid hemorrhage will help guide further treatment. Common workup includes either a CT angiogram (CTA) of the head and neck, magnetic resonance angiography (MRA) of the head and neck, or diagnostic cerebral angiogram of the head and neck done emergently to look for an aneurysm, AVM or another source of subarachnoid hemorrhage.
Laboratory studies should also be considered including a complete blood count to check for thrombocytopenia, coagulation studies (PTT, PT/INR) to check for coagulopathy and basic metabolic panel to check for electrolyte abnormalities.
Intraparenchymal Hemorrhage
Once the medical stability of the patient is ensured, CT head without contrast is the first diagnostic test most commonly performed. The imaging should be able to identify acute intraparenchymal hemorrhage as hyperdense within the parenchyma. Depending on the history, physical and imaging findings and patient an MRI brain with and without contrast should be considered as tumors within the brain may present as intraparenchymal hemorrhage. Other imaging to consider include CTA, MRA or diagnostic cerebral angiogram to look for cerebrovascular causes of the intraparenchymal hemorrhage. Evaluation should also include a complete neurologic exam to identify any neurologic deficits.
Laboratory studies should also be considered including a complete blood count to check for thrombocytopenia, coagulation studies (PTT, PT/INR) to check for coagulopathy and basic metabolic panel to check for electrolyte abnormalities.
Treatment of Intracranial Hemorrhage
Treatment depends substantially on the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.
Do no HARM for 72 hours after injury
- Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
- Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
- Running, and walking may cause further damage, and causes healing delay.
- Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.
Medication
The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
- Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
- Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
- Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health.
- Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
What To Eat and What to avoid
Eat Nutritiously During Your Recovery
All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.
- One review found that antihypertensive therapy to bring down the blood pressure in acute phases appears to improve outcomes.[rx] Other reviews found an unclear difference between intensive and less intensive blood pressure control.[rx][rx] The American Heart Association and American Stroke Association guidelines in 2015 recommended decreasing the blood pressure to a SBP of 140 mmHg.[1] However, the evidence finds tentative usefulness as of 2015.[rx]
- Giving Factor VIIa within 4 hours limits the bleeding and formation of a hematoma. However, it also increases the risk of thromboembolism.[rx] It thus overall does not result in better outcomes in those without hemophilia.[rx]
- Frozen plasma, vitamin K, protamine, or platelet transfusions may be given in case of a coagulopathy. Platelets however appear to worsen outcomes in those with spontaneous intracerebral bleeding on antiplatelet medication.[rx]
- Fosphenytoin or other anticonvulsant is given in case of seizures or lobar hemorrhage.[rx]
- H2 antagonists or proton pump inhibitors are commonly given for to try to prevent stress ulcers, a condition linked with ICH.[rx]
- Corticosteroids were thought to reduce swelling. However, in large controlled studies, corticosteroids have been found to increase mortality rates and are no longer recommended.
Surgery
Surgery is required if the hematoma is greater than 3 cm (1 in), if there is a structural vascular lesion or lobar hemorrhage in a young patient.[rx]
- A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures.[rx]
- Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited.[rx]
- A craniectomy may take place, were part of the skull is removed to allow a swelling brain room to expand without being squeezed.
