Intracranial Hemorrhage – Causes, Symptoms, Treatment

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

Types of Intracranial Hemorrhage

intracranial hemorrhage

Intra-axial hemorrhage

• signs and formulas
  • • ABC/2 (volume estimation)
    • CTA spot sign
    • swirl sign

• By region or type

• • • basal ganglia hemorrhage
    • cerebellar hemorrhage
      • remote cerebellar hemorrhage
    • cerebral contusions
    • cerebral microhemorrhage
    • ​hemorrhagic venous infarct
    • hemorrhagic transformation of an ischemic infarct
      • cerebral intraparenchymal hyperattenuations post thrombectomy
    • hypertensive intracranial hemorrhage
    • intraventricular hemorrhage (IVH)
    • jet hematoma
    • lobar hemorrhage
      • cerebral amyloid angiopathy
    • pontine hemorrhage
      • Duret hemorrhage
• Extra-axial hemorrhage
  • extradural versus subdural hemorrhage
  • extradural hemorrhage (EDH)
    • venous extradural hemorrhage
  • intralaminar dural hemorrhage
  • subdural hemorrhage (SDH)
    • calcified chronic subdural hemorrhage
  • subarachnoid hemorrhage (SAH)
    • types
      • ruptured berry aneurysm
        • berry aneurysm
        • fusiform aneurysm
        • mycotic aneurysm
      • convexal subarachnoid hemorrhage
      • traumatic subarachnoid hemorrhage (TSAH)
      • perimesencephalic subarachnoid hemorrhage (PMSAH)
    • vasospasm following SAH
    • grading systems
      • Hunt and Hess grading system
      • Fisher scale
      • modified Fisher scale
      • SDASH score
      • WFNS grading system
  • subpial hemorrhage

Causes of Intracranial Hemorrhage

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 arterial epidural hematoma.[rx]

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

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 an aneurysmal and non-aneurysmal subarachnoid hemorrhage. Aneurysmal subarachnoid hemorrhage occurs after the 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.[rx]

Intraparenchymal Hemorrhage

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

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 the 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.

Symptoms of Intracranial Hemorrhage

Symptoms of a brain hemorrhage depend on the area of the brain involved. In general, symptoms of brain bleeds can include:

• Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body.
• Headache. (Sudden, severe “thunderclap” headache occurs with subarachnoid hemorrhage.)
• Nausea and vomiting.
• Confusion.
• Dizziness.
• Seizures.
• Increasing headache
• A sudden severe headache
• Seizures with no previous history of seizures
• Weakness in an arm or leg
• Decreased alertness; lethargy
• Changes in vision
• Tingling or numbness
• Difficulty speaking or understanding speech
• Difficulty swallowing
• Difficulty writing or reading
• Loss of fine motor skills, such as hand tremors
• Loss of coordination
• Loss of balance
• An abnormal sense of taste
• Drowsiness and progressive loss of consciousness
• Unequal pupil size
• Slurred speech
• Loss of balance or coordination.
• Stiff neck and sensitivity to light.
• Abnormal or slurred speech.
• Difficulty reading, writing or understanding speech.
• Change in level of consciousness or alertness, lack of energy, sleepiness or coma.
• Trouble breathing and abnormal heart rate (if the bleed is located in the brainstem).

Diagnosis of Intracranial Hemorrhage

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

Epidural Hematoma

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.[rx][rx][rx]

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 subdural 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. A 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 of Intracranial Hemorrhage

Treatment depends substantially on the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.

• Tracheal intubation is indicated in people with a decreased level of consciousness or another risk of airway obstruction.^[rx]
• IV fluids are given to maintain fluid balance, using isotonic rather than hypotonic fluids.^[rx]

Medication

• One review found that antihypertensive therapy to bring down the blood pressure in acute phases appears to improve outcomes.^[rx] Other reviews found an unclear difference between intensive and less intensive blood pressure control.^[rx][rx] The American Heart Association and American Stroke Association guidelines in 2015 recommended decreasing the blood pressure to a SBP of 140 mmHg.^[1] However, the evidence finds tentative usefulness as of 2015.^[rx]
• Giving Factor VIIa within 4 hours limits the bleeding and formation of a hematoma. However, it also increases the risk of thromboembolism.^[rx] It thus overall does not result in better outcomes in those without hemophilia.^[rx]
• Frozen plasma, vitamin K, protamine, or platelet transfusions may be given in case of a coagulopathy. Platelets however appear to worsen outcomes in those with spontaneous intracerebral bleeding on antiplatelet medication.^[rx]
• Fosphenytoin or other anticonvulsant is given in case of seizures or lobar hemorrhage.^[rx]
• H2 antagonists or proton pump inhibitors are commonly given for to try to prevent stress ulcers, a condition linked with ICH.^[rx]
• Corticosteroids were thought to reduce swelling. However, in large controlled studies, corticosteroids have been found to increase mortality rates and are no longer recommended.

Surgery

Surgery is required if the hematoma is greater than 3 cm (1 in), if there is a structural vascular lesion or lobar hemorrhage in a young patient.^[rx]

• A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures.^[rx]
• Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited.^[rx]
• A craniectomy may take place, were part of the skull is removed to allow a swelling brain room to expand without being squeezed.