Intracranial Hemorrhage
A. See also
B. Epidural hematoma
1. H&P: Typically, head trauma with brief LOC; then lucid interval, then obtundation, contralateral hemiparesis, and ipsilateral pupil dilatation.
2. Cause: Injury to the meningeal artery or its branches.
3. Rx: Epidural hematomas should go to the OR immediately.
C. Subdural hematoma (SDH)
1. DDx: Epidural hematoma, subdural empyema, cerebral atrophy.
2. Causes:
a. Acute SDH: Usually follows trauma (injury to the bridging veins).
b. Chronic spontaneous SDH: In the elderly, especially with cerebral atrophy, alcoholism; or poor hemostasis.
3. Rx of SDH:
a. Symptomatic SDH should be surgically drained.
b. Asymptomatic SDH may be watched.
c. Seizure prophylaxis: If acute, s/p seizure, or s/p surgical intervention. Often started on AED for ∼3 wk, then d/c if no seizures.
D. Subarachnoid hemorrhage (SAH)
1. Traumatic vs. spontaneous SAH: Nontraumatic SAH is an emergency; needs immediate angiogram to r/o aneurysm. Traumatic SAH
can usually be watched. Make sure the head trauma preceded LOC, not vice versa.
2. H&P in spontaneous SAH: Sudden, severe HA—“worst HA in my life.” N/V, LOC, stiff neck, cranial nerve deficits (especially third nerve), obtundation, ocular hemorrhage.
3. Causes of SAH:
a. Trauma: Most SAH are traumatic.
b. Aneurysms: 75% of spontaneous SAH are ruptured aneurysms.
1) Location: 75% anterior circulation; 25% posterior. 25% have multiple aneurysms.
2) Associations with aneurysms: Polycystic kidney dz, fibromuscular dysplasia, AVMs, Ehlers-Danlos syndrome type IV, Marfan’s, aortic coarctation, Osler-Weber-Rendu syndrome.
c. Idiopathic: 15% of all spontaneous SAH. Associated with cigarettes, oral contraceptives, HTN, alcohol.
d. Other: AVMs, vasculitis, carotid/vertebral artery dissection.
4. Tests in spontaneous SAH:
a. Blood: CBC, PT, PTT, blood bank sample with 6 units held for OR, DPH level if pt has received it.
b. EKG: For arrhythmia, MI, cerebral Ts, long QT, U waves.
c. Head CT: see p. 180 for CT appearance.
d. LP if CT negative: See CSF table (Table 3, p. 19). SAH has high opening pressure, blood that does not clear in successive tubes, xanthochromia if bleed >6 h. WBC may be secondarily high.
e. Emergent angiogram: For spontaneous SAH, to r/o correctable aneurysm. Consider calling angiographers to prepare them when you first know of pt. Angiogram and early intervention are especially indicated in pts with Hunt-Hess (H-H) grade 1-3 because of good prognosis. For H-H 4-5, prognosis is poor; thus, reassess frequently and consider treatment if pt improves after ventriculostomy.
1) Angiogram-negative spontaneous SAH: Repeat angio in 2 wk.
5. Prognosis in SAH:
a. Mortality: 30% die before reaching hospital; 10% more in first few days. 50% total in first month.
Table 11. Hunt-Hess clinical grading scale, diagnostic testing, and prognosis for subarachnoid hemorrhage.
H-H
Grade
SAH Symptoms
Tests and Prognosis
0
Unruptured aneurysm (incidental finding)
F/u MRIs, ~1% a yr rupture
1
Mild HA, stiff neck
3 Drowsy/confused ± mild focal deficit
2
Severe HA/stiff neck ± cranial nerve sx
3
Drowsy/confused ± mild focal deficit
4
Stupor, hemiparesis, ± mild decerebration
Angio only if pt better after EVD
5
Deep coma, decerebrate posturing
Poor; usually palliative care
b. Morbidity: 50%-60% have serious deficit even with successful clipping.
c. Rebleeding risk: With unclipped aneurysm, 15% rebleed in 14 d, 50% in 6 mo, then 3%/yr. Hypertension greatly increases rebleed risk.
d. Hunt-Hess (H-H) grading in SAHRelated posts:
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