What is an epidural hemorrhage? And what is shape seen on CT?
Occurs between the skull and the dura, typically from an artery, especially the middle meningeal artery. Convex, or lemon/lens shaped hematoma. Often have an associated skull fracture.
What is a subdural hemorrhage? And what is shape seen on CT?
Occurs between the dura and the thin arachnoid layer covering the brain, typically from a torn or ruptured bridging vein between the dura and the cortex. This layers like a banana (i.e. concave).
What is a subarachnoid hemorrhage?
Occurs right next to the brain, underneath the arachnoid layer. Trauma is the most common cause, but everyone is more concerned with the spontaneous (i.e. non-traumatic) version from aneurysms, AVM, or other causes.
What is an intra-parenchymal hemorrhage?
Formed blood clots, which dissect into the brain. These can be anywhere, and have many causes.
What is an intra ventricular hemorrhage?
Any Hemorrhage that finds it’s way into the Ventricular system. Rarely, intraventricular hemorrhage can occur in isolation (without hemorrhage in any other compartment).
When does hemorrhagic transformation of ischemic stroke bed occur?
With large vessel cortical strokes. This can be asymptomatic if mild ‘bruising’ or fatal if a large formed hematoma.
What is the presentation of a ruptured intracranial aneurysm?
Hemorrhages, either subarachnoid or intraparenchymal, similarly present with sudden onset of neurological deficits, but typically have associated headache, nausea, and vomiting along with a depressed level of consciousness. The onset of non-traumatic subarachnoid hemorrhage is cataclysmic and often described as a firecracker or explosion in the head, creating a severe headache. Some patient claim it’s the “worst headache of their life”.
What is the presentation of a ruptured intracerebral hemorrhage?
Typically begin with a mild headache, deficit, maybe some nausea, and progress over a few minutes to hours adding decreased level of consciousness. The family often will describe a hemiparesis steadily progressing into hemiplegia and a level of consciousness that steadily deteriorates into coma. Like ischemic stroke, the exact symptoms can vary based on the anatomical location and size of the bleeding. Generally a disorder of aging and hypertension, younger patients with stimulant use are at risk. For unclear reasons, Intraparenchymal Hemorrhage is more common than ischemic stroke in China and other parts of Asia.
What is the presentation of a subdural hemorrhage?
Due to trauma or spontaneous Acute: confusion, lethargy, coma, focal neurologic symptoms, seizures, HA, dizzines, N/V, ataxia Older people - their brains shrink and has more space to jostle around in the head and tear bridging veins Spontaneous Subdural Hemorrhage can be relatively asymptomatic, and progress to a “Chronic Subdural Hemorrhage” which enlarges over days to months. Chronic: headache, vomiting, limb weakness/spasticity, speech difficulties, confusion, drowsiness, seizures, impaired consciousness, focal neurological deficit
What is the presentation of an epidural hemorrhage?
injury → groggy → lucid interval!!!!! → then worsens (stereotypical, not present in all pts) From traumatic temporal bone fracture that tears the middle meningeal artery
What is the mechanism of intraparenchymal hemorrhage?
Often due to HTN and age. Some are from coagulation disease or therapeutic anticoagulation. They typically occur in the Basal Ganglia (Putamen), Thalamus, Pons and Cerebellar deep grey matter. When in atypical locations, such as the deep white matter (“lobar hemorrhages”) they can still be from age/HTN, but can also be from AVM’s (arteriovenous malformations), aneurysms, vasculitis, bleeding disorders, or even hemorrhage into tumors.
What is amyloid angiopathy?
Patients get recurrent lobar hemorrhages that lead to progressive dementia and disability. These lobar hemorrhages can be curiously well-tolerated in many. Amyloid deposition is found in the vessels (intramural). This disorder is different from systemic amyloidosis or to Alzheimer’s amyloid plaques, but can sometimes be found in conjunction with Alzheimer’s Disease.
What is the mechanism of a subdural hemorrhage?
Usually trauma that was not reported or suspected. Once in a while, coagulopathy or “small brains in large skulls” present with no history of trauma. Perhaps it’s better to think of this as from ‘trivial’ traumas. The bridging veins in the subdural space tear easily, especially in elderly patients with more brain atrophy and this causes a lower pressure, slower bleeding process.
What is the mechanism of an epidural Hemorrhage?
The Epidural space contains the Middle Meningeal Artery, which often will tear from a skull fracture creating an Epidural Hematoma. Since this is an arterial high-pressure bleed, the progression can be rapid.
What is the mechanism of subarachnoid hemorrhage?
When not from trauma (most common), is due to aneurysmal rupture (80%), or to arteriovenous malformation (15%). The other 5% is never discovered. Some people have “benign” peri-mesencephalic SAH that is curiously unassociated with aneurysm or AVM.
What are the two main strategies for medical therapies used to PREVENT hemorrhage?
- Optimal control of blood pressure and other vascular risk factors (smoking cessation is particularly important for aneurysmal SAH prevention) 2. Anti-platelet or anticoagulants will paradoxically help prevent recurrent hemorrhage if caused by an initial ischemic event, followed by hemorrhagic transformation
What is the emergency management for intracranial hemorrhage? (procedures and medical management if procedure not possible)
Often, the placement of an intracranial pressure monitoring device, or drainage device (ventriculostomy) is all that is necessary. Other types of hemorrhage require emergency surgery. The window of opportunity to intervene here can be short, so rapid diagnosis remains the crucial factor. While waiting for a procedure or if not possible: reduction of intracranial pressure by a combination of diuresis and reduction of blood pCO2. Mannitol traditionally is used, however, traditional loop diuretics are effective, too.
Treatment of subarachnoid hemorrhage
Physical intervention (surgery, catheter-based ablation, both) of aneurysm or AVM during the first few days of hospitalization. Patients actually benefit by sedation and relative hypotension (if possible) because it can reduce the risk of re-bleeding before surgical intervention. Treatment with Nimodipine and Statins help reduce the amount of ischemic damage from vasospasm, a process caused by irritation of blood vessels by the blood in the subarachnoid space. After surgical obliteration of the bleeding source, maintaining normal to high BPs, normovolemia, angioplasty, vasodilator meds, and other therapies can be used to reduce the effects of vasospasm.
Treatment of subdural and epidural hemorrhage
Treatment of intraparenchymal hemorrhages
Only sometimes need surgery Can often be medically treated, or if severe, surgery has little benefit. Occasional drainage of the hemorrhage, treatment of hydrocephalus, and placement of intracranial pressure monitoring routinely are performed
Should you do surgical intervention in stable unruptured intracranial aneurysms and asymptomatic arterial venous malformations?
Unclear whether good or bad Weigh immediate risk with long-term benefit Bigger aneurysm is more at risk Top of the basilar aneurysms are particularly risky to ‘watch’.
Rt of AVM bleed/year?
Deep vs lobar intracerebral hemorrhage
Deep: Where small, perforating arteries are (basal ganglia, thalamus, pons, cerebellar); risk factors are HTN and age; poorly-tolerated Lobar: Amyloid angiopathy; risk factors are AGE, dementia, coagulopathy; HTN (1/3-less than deep); well-tolerated; less common than deep
How does subarachnoid hemorrhage look on CT?
Starfishing or “Star of death”
AVM- Abnormal connection between artery and vein without capillary bed Congenital Increased risk of hemorrhage