Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds (intraventricular bleeds and intraparenchymal bleeds), subarachnoid bleeds, epidural bleeds, and subdural bleeds. More often than not it ends in a lethal outcome. Intracerebral bleeding affects 2.5 per 10,000 people each year. Signs and symptoms
Intracranial hemorrhage is a serious medical emergency because the buildup of blood within the skull can lead to increases in intracranial pressure, which can crush delicate brain tissue or limit its blood supply. Severe increases in intracranial pressure (ICP) can cause brain herniation, in which parts of the brain are squeezed past structures in the skull. Causes
Trauma is the most common cause of intracranial hemorrhage. It can cause epidural hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage. Other condition such as hemorrhagic parenchymal contusion and cerebral microhemorrhages can also be caused by trauma.Non-traumatic causes of hemorrhage includes: hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarction, cerebral aneurysms, dural arteriovenous fistulae, cerebral venous sinus thrombosis, cerebral vasculitis and mycotic aneurysm.More than half of all cases of intracranial hemorrhage are the result of hypertension. Diagnosis
CT scan (computed tomography) of the brain (without any iodinated contrast), is the initial imaging choice because of its high speed, good accessibility in hospitals, high sensitivity in detecting brain injuries or brain diseases, thus helping to triage patients in emergency department in a timely manner and urgent neurosurgical intervention can be administered. Examples of brain diseases that require urgent intervention are: large volume hemorrhage, brain herniation, and cerebral infarction.
These are pseudoaneurysm, caused by thrombus clogging the distal arteries, which results in inflammation and small tears at the site of occlusion. These inflammation and thrombis can caused by infective endocarditis, artificial heart valve or other heart problems. Similar to vasculitis, rupture of mycotic aneurysm also causes SAH in cerebral sulci, mostly located in the vertex. If mycotic aneurysm is located more proximally, it will produce diffuse SAH pattern. CTA or MRA would produce focal outpouching or increase in diameter of the vessel. Meanwhile, GRE/SWI MRI sequence would produce focal hypointensity. Small mycotic aneurysms are difficult to be seen on CT or MRI. Thus, DSA is useful in identifying these lesions. Management
For those who is already on blood thinners such as aspirin or clopidogrel for prevention of myocardial infarction or stroke, traumatic intracranial hemorrhage should prompt the use of platelet function assays (PFA-100) to assess the effect of these antiplalelet agents. After that, plateletpheresis can be started to increase the aggregation of platelets, thus stopping the intracranial bleed. In those with impaired kidney functions, desmopressin or cryoprecipitate can be used instead.From limited observational data, it may be relatively safe to restart blood thinners after an ICH as it is asscoated with reduced thromboembolic complications with similar risk of recurrent hemorrhage when compared to those did not start blood thinners after an ICH. Comparison
References
Further reading
Shepherd S. 2004. "Head Trauma." Emedicine.com. Vinas FC and Pilitsis J. 2004. "Penetrating Head Trauma." Emedicine.com. Julian A. Mattiello, M.D., Ph.D. Michael Munz, M.D. 2001.