Intracranial Hemorrhage


Article Author:
Steven Tenny


Article Editor:
William Thorell


Editors In Chief:
Rodrigo Kuljis
Oleg Chernyshev
Aninda Acharya


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/19/2019 1:13:34 AM

Introduction

Intracranial hemorrhage encompasses four broad types of hemorrhage: epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and intraparenchymal hemorrhage.[1][2][3] Each type of hemorrhage is different concerning etiology, findings, prognosis, and outcome. This article provides a broad overview of the types of intracranial hemorrhage.

Etiology

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 the arterial epidural hematoma.[4]

A venous epidural hematoma occurs when there is 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 blunt head injury but may also occur after penetrating head injuries or spontaneously.[5][6]

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 aneurysmal and non-aneurysmal subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage occurs after 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.[7]

Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage is bleeding into the brain parenchyma proper. There are a wide variety of reasons such hemorrhage can occur including, but not limited to, hypertension, arteriovenous malformation, amyloid angiopathy, aneurysm rupture, tumor, coagulopathy, infection, vasculitis, and trauma.

Epidemiology

Epidural Hematoma 

Epidural hematomas are present in approximately 2% of head injury patients and account for 5% to 15% of fatal head injuries. Approximately 85% to 95% of epidural hematomas have an overlying skull fracture. 

Subdural Hematoma

The incidence of subdural hematoma is estimated to be between 5% to 25% of patients with a significant head injury.  There is an annual incidence of one to five cases per 100,000 population per year with a male to female ratio of 2:1. The incidence of subdural hematomas increases throughout life.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage accounts for approximately 5% of all strokes and has an incidence of approximately two to 25 per 100,000 person-years for those over the age of 35. The incidence trends up slowly as patients age and may be very slightly more frequent in females than males (1.15:1 for the female to male ratio).

Intraparenchymal Hemorrhage 

Intraparenchymal hemorrhage accounts for 10% to 20% of all strokes.  Intraparenchymal hemorrhage incidence increases for those age 55 and older with increasing incidence as age increases. There is some controversy regarding gender differences, but there may be a slight male predominance.

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 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.

History and Physical

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 of after the injury, followed by a lucid interval then neurologic deterioration. This classic presentation only occurs in less than 20% of patients. Other symptoms which are common include a 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 a 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.

Evaluation

Epidural Hematoma[8][9][10]

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.

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 subdurals 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. 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 / Management

Epidural Hematoma[11][12][13]

Treatment begins with advanced trauma life support (ATLS) including airway control, ensuring adequate ventilation and circulation. Intravenous (IV) access should be secured. If the patient has a Glasgow Coma Score (GCS) of 8 or less or worsening neurologic status, intubation should be performed. Immediate neurosurgical consultation should be obtained for patients with epidural hematomas as they may expand over time due to continued bleeding. Definitive treatment is an evacuation of the hematoma and stopping the bleeding source. Some smaller epidural hematomas may be managed non-surgically and watched closely for resolution.

Subdural Hematoma

Treatment begins with ensuring adequate airway, breathing, and circulation. Intubation should be considered if the patient has a deteriorating GCS or GCS of 8 or less. Immediate neurosurgical consultation should be obtained as emergency surgery may be required to evacuate the subdural hematoma. Definitive treatment for subdural hematomas is an evacuation, but depending on the size and location some subdural hematomas may be watched for resolution.

Non-surgical management options include repeat imaging to ensure subdural stability, reversal of anticoagulation, platelet transfusions for thrombocytopenia or dysfunctional platelets, observation with frequent neurologic assessments for deterioration, and/or controlling hypertension. There is controversy about whether steroids can help stabilize the size of the subdural hematoma while giving it time to resorb or until surgical treatment.

Surgical management options include twist drill hole, burr hole(s), and craniotomy for evacuation. Data suggests that a twist drill hole has the lowest surgical complication rate with the highest recurrence rate. A craniotomy has the highest surgical complication rate with the lowest recurrence rate of the surgical options, and burr hole(s) evacuation falls somewhere between a twist drill hole and a craniotomy for complication rate and recurrence rate.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage may depend if it is traumatic or non-traumatic subarachnoid hemorrhage. For traumatic subarachnoid hemorrhage, the ABCs of medicine must occur first. Early consultation with neurosurgery should be considered. If the patient is on anticoagulation or antiplatelet agents consideration should be given to reversing their effects. Care is typically conservative with close assessments of vitals and neurologic status. In obtunded patients, there may be a need for an intracranial pressure (ICP) monitor and/or external ventricular drain (EVD). Patients should be monitored for hydrocephalus or cerebral swelling. Repeat imaging can verify improvement of the traumatic subarachnoid hemorrhage. Sometimes aneurysmal rupture or incompetence of other intracranial vascular malformations can masquerade as traumatic subarachnoid hemorrhage. If there is no clear and convincing history of a traumatic origin, then a non-traumatic etiology for the subarachnoid hemorrhage should be sought.

In non-traumatic subarachnoid hemorrhage, the etiology of the hemorrhage must be ascertained and addressed. Early consultation with neurosurgery should be considered. Treatment varies depending on the etiology of the hemorrhage but can include treatment of an aneurysm or arteriovenous malformation or other etiology. Additionally, there should be a low threshold for placement of an external ventricular drain (EVD) due to the risk of hydrocephalus.

Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage can be life-threatening and treatment starts with the ABCs of medicine and stabilization of the patient.  Blood pressure should be controlled to decrease the risk of further hemorrhage. Early consultation with neurosurgery should be considered. The treatment of intraparenchymal hemorrhage depends on the etiology of the hemorrhage. Treatment options are variable and include aggressive surgical evacuation, craniectomy, catheter-based dissolution or observation. Surgical evacuation is controversial for some forms of intraparenchymal hemorrhage. Although many intraparenchymal hemorrhages are secondary to cerebrovascular disease and hypertension, the surgeon should anticipate encountering other underlying pathology including an aneurysm, AVM, and/or tumor when evacuating an intraparenchymal hemorrhage. Sometimes evacuation of the hematoma may be more detrimental than the hematoma itself, and a craniectomy is performed instead to allow for cerebral swelling. There are a number of catheter-based systems which try to dissolve the hemorrhage. Discussion of these is beyond the scope of this article. Smaller and non-operable hemorrhages may be managed medically with control of blood pressure, reversal of anticoagulation or antiplatelet agents, and neuroprotective strategies to prevent and/or mitigate secondary cerebral injury.

Enhancing Healthcare Team Outcomes

Patients who present with CNS bleeding are best managed by a multidisciplinary team that includes a neurologist, neurosurgeon, radiologist, intensivist, neurosurgery nurses, physical therapist, pulmonologist and other allied health specialists like speech, occupational and physical therapists. Many of these patients need admission to the ICU and the care depends on the degree of physical and other neurological deficits. The outcomes depend on the type and extent of bleed, age, other comorbidity and severity of neurological deficit at the time of admission. [14][7][15]


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Intracranial Hemorrhage - Questions

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A patient presents to the emergency department with a severe headache and is suspected of having a subarachnoid bleed. What is the next step in the investigation?



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An older patient on coumadin with a cerebellar hemorrhage is in the intensive care unit. Appropriate reversal agents for his coagulopathy were previously administered and the patient’s last INR was 1.2 this morning. His mental status suddenly declines. Which of the following is true regarding the management of this patient when managing spontaneous intracranial hemorrhage (ICH)?



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What are the MR signal characteristics of EARLY SUBACUTE bleeds?



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Excluding trauma, which statement is true about intracranial hemorrhage?



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What are the MR signal characteristics of chronic intracranial hemorrhage?



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A 17-year-old student is hit in the head with a baseball during a baseball game. Per report, he was unconscious for a few minutes before awakening with a headache. He is transported to the hospital where a CT scan shows a 4 mm epidural hematoma. Over the next two hours, he becomes increasingly lethargic in the emergency department with Glasgow coma scale (GCS) deterioration from 13 to 8. What is the next best step in management?



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A 68-year-old female has progressive headaches and worsening confusion since a fall in the garden one month ago. She takes hydrochlorothiazide for hypertension and warfarin for atrial fibrillation. Neurologic exam identifies some confusion and trouble following complex commands but no focal motor deficits. Laboratory workup is unremarkable except for her INR of 2.1. A urine analysis is normal. The chest x-ray is normal. There is suspicion for intracranial hemorrhage. What is the most likely pathology?



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A 45-year-old female was at the grocery store shopping when she reportedly grabbed her head then collapsed to the ground. At the hospital, she had a Glasgow coma score (GCS) of 7. CT of the head showed diffuse acute blood in the subarachnoid spaces and cisterns with hydrocephalus. What is the most likely etiology of her intracranial hemorrhage?



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An 85-year-old male was brought to the emergency department with a right-sided facial droop and weakness of the right arm which occurred suddenly while watching the athletic event on television. He has a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease and benign prostatic hyperplasia. A workup revealed intracranial hemorrhage on the left. What percentage of strokes are hemorrhagic?



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A 91-year-old female becomes acutely unresponsive in her assisted living care facility. She is taken to the hospital for a stroke workup and found to have a right frontal intraparenchymal hemorrhage with intraventricular extension. Estimated blood volume of the hemorrhage is 65 mL. She takes warfarin for non-valvular atrial fibrillation and has an INR of 2.1. She has hypertension, diabetes mellitus, asthma, gastroesophageal reflux disease, and stress incontinence. On initial exam, her eyes do not open to painful stimuli, she moans and withdrawals to noxious stimuli in the right arm and has extensor posturing in the left arm with extension of bilateral legs. What is her 30-day mortality based on the intracerebral hemorrhage score?



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A 60-year-old male has a sudden onset of extreme dizziness, nausea, and vomiting while at work. He is taken to the hospital for a stroke workup. On exam, he opens his eyes to voice, is oriented to conversation, follows commands with all extremities and has profound bilateral dysmetria of the upper and lower extremities. His blood pressure is 180/100 mmHg, heart rate of 102 bpm, and oxygen saturation of 98% on room air. Imaging reveals a cerebellar hemorrhage of the bilateral cerebellar hemispheres with 40 mL of estimated blood volume and effacement of the fourth ventricle with lateral ventricular enlargement. There does not appear to be any blood in the ventricular system. What is his 30-day mortality based on the intracerebral hemorrhage (ICH) score?



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A 10-year-old male falls off of his bicycle while visiting a national park. He has acute onset of headache and one episode of emesis. He is treated at the local ranger station and is stable and dismissed as the headache improved. One week later he back home and slips on the soap in the shower and falls. He is brought to the emergency department due to headache. He is alert and awake and has a mild diffuse headache without nuchal rigidity. There is no reported loss of consciousness. He is neurologically intact. A computed tomography (CT) scan of the head identifies an isodense three mm-thick lenticular shaped fluid collection in the right superior frontal region stopping at the coronal suture. His lab work is within normal limits for a complete blood count and basic metabolic panel. No obvious skull fractures are identified. What is the best initial management for this patient?



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A 67-year-old widowed male has a progressive headache for two weeks. For the past three days, he has been increasingly confused during his daily telephone conversations with his daughter who lives out of town. She called emergency medical services, and the patient is taken to the hospital. The patient is mildly confused, repeating himself often, but otherwise, alert without weakness. His lab workup is unremarkable including complete blood count, complete metabolic panel, urine analysis and chest x-ray. A computed tomography (CT) scan of the head identifies a 1.4 cm right subdural hematoma with mixed density. The patient's daughter states two weeks ago the patient was very mentally sharp and never repeated himself. She states the would want definitive treatment with the lowest likelihood of recurrence. Which options provides the least likelihood of recurrence of the subdural hematoma for this patient?



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Intracranial Hemorrhage - References

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The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Neurology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Neurology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Neurology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Neurology. When it is time for the Neurology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Neurology.