Intracranial hemorrhage

  • Hematoma/hemorrhage
  • Epidural , subdural hematoma
  • Intracerebral , intraventricular hemorrhage, SAH
  • Vascular Abnormality

Aneurysm

AVM

Chronic subdural haematoma

  • Often minor injuries or no history of injury
  • Several weeks after injury
  • “the great imitator” (of dementia, tumours, etc...)
  • risk factors: older, alcoholic, patients with CSF shunts, anticoagulants
  • expands due to repeated bleeding
  • brain usually undamaged
  • CT: low density concave mass
  • management: burr hole drainage

 

SPONTANEOUS INTRACEREBRAL HEMORRHAGE (ICH)

  • Definition

          Bleeding into brain parenchyma without accompanying trauma

  • can dissect into ventricular system (IVH) or through cortical surface (SAH)

Etiology - usually determines location

  • Hypertension (40-60%) - deep gray matter/basal ganglia, thalamus,pons, cerebellum
  • Aneurysm (20%)
  • AVMs (5-7%) – anywhere
  • Coagulopathies (5-7%) - cortical and subcortical, especially cerebellum
  • Tumours (1%) - anywhere e.g. malignant melanoma, choriocarcinoma
  • Hemorrhagic infarcts - cortical and subcortical
  • cavernous malformations – anywhere
  • cerebral amyloid (congophilic) angiopathy - subcortical lobar (usually elderly patients)
  • Drugs (amphetamines, cocaine, etc...)

30 day mortality rate is 44%, mostly due to cerebral herniation

  • specific symptoms depend on location of ICH

Diagnosis

  • high density blood on CT without contrast
  • MRI does not show blood immediately - not procedure of choice

Management

  • Medical
  • correct HTN, coagulopathy
  • control ICP (mannitol, hyperventilate, elevate head of bed)
  • anticonvulsants
  • Surgical
  • craniotomy with evacuation of clot under direct vision,
  • resection of source of ICH ( AVM, tumour,Cavernoma),
  • ventriculostomy to treat HCP

 

Subarachnoid hemorrhage (SAH)

  • Etiology

Trauma (most common)

Spontaneous

  • Aneurysms (75-80%)
  • Idiopathic (14-22%)
  • AVMs (5%)
  • Infections e.g. mycotic aneurysms

Clinical presentation

  • Sudden onset severe headache: “worst headache of my life”
  • Vomiting, nausea (increased ICP)
  • Meningismus (neck stiffness, photophobia, positive Kernig’s and Brudzinski’s sign)
  • Decreased level of consciousness
  • sentinel/warning leaks
  • small SAH with sudden severe H/A +/– transient focal neurological deficit

Diagnosis

  • blood on CT or LP
  • 30-60% of patients with full blown SAH give history suggestive of a warning leak

Clinical Course/Natural History

  • 10-15% die before reaching hospital
  • overall mortality 50-60% in first 30 days
  • major cause of mortality is rebleeding
  • risk of rebleeding: 4% on first day, 15-20% within 2 weeks, 30% by 6 months
  • if no rebleed by 6 months chance of rebleeding decreases to same incidence of unruptured aneurysm (2%)

Diagnosis

  • CT Brain
  • LP
  • MRI and MRA
  • DSA(Digital Subtraction Angiography

Management

  • bed rest, elevate head (30 degrees), minimal external stimulation
  • control HTN, avoid hypotension since CBF autoregulation impaired by SAH
  • prophylactic anticonvulsant: short course of Dilantin (2 weeks)
  • neuroprotective agent: nimodipine
  • Early surgery to prevent rebleed
  • Intraventricular catheter if acute HCP present
  • “Triple H” therapy for vasospasm: hypertension, hypervolemia, hemodilution
  • Angioplasty for refractory vasospasm

Surgical treatment

  • Clipping
  • Endovascular Intervention with coils