Intracranial hemorrhage

Brief presentation

1. INTRACRANIAL HEMORRHAGE Bibek Kandel Gandaki Medical College

2. C ontent Introduction Classification Aetiology Clinical Presentation Clinical Approach Complications Management

3. Introduction is bleeding within the skull life threatening emergency

4. Depending on location grouped into intra-axial and extra-axial intra axial— intraparencymal intraventricular extra axial - EDH , SDH , SAH

5. Aetiology HTN Trauma Advanced Age Hemorrhagic Disorders Vascular Malformations Heavy Alcohol Consumption Cocaine & Amphetamine Use Neoplasms Spontaneous rupture of the penetrating arteries

6. Epidural Hemorrhage 2-4 % cases of head trauma occur between the dura mater and the skull m ainly arterial bleed Patients have a loss of consciousness (LOC), then a lucid interval, then sudden deterioration (vomiting, restlessness, LOC) Head CT shows lenticular (convex) deformity.

7. Subdural hemorrhage 20% of head trauma Results from tearing of the bridging veins in the space between the dura and arachnoid mater. Acute , subacute and chronic type Chronic type may progress to Chronic Subdural Hygroma M ainly due to injury to cortical veins LOC immediately after trauma C onvulsion is common F eatures of increased ICP ,focal neurological deficits or hemiparesis Head CT shows crescent-shaped deformity

8. Subarachnoid hemorrhage B leeding into the subarachnoid space O ccur spontaneously, usually from a ruptured cerebral aneurysm. S evere headache (thunderclap headache), Vomiting, C onfusion or a lowered level of consciousness, S eizures. Lumbar puncture-blood stained CSF , CT scan , Carotid & vertebral angiogram

9. Intra Axial Hemorrhage Intraparenchymal and Intraventricular Cerebral, basal ganglia ,lobar , pontine ,basal ganglia, cerebellar hematoma are intraparenchymal Facial palsy , hemiplegia ,weakness of limb Slurred speech ,elevated blood pressure Seizures , headache , dizziness , vertigo More dangerous and harder to treat

10. Intraventricular hematoma

11. Clinical Approach History : history of onset , injury , alcohol intake , LOC , Vomiting , ENT bleed , CSF rhinorrhea & otorrhea , amnesia, and about risk factors Neurological Assessment: Level of consciousness , Glasgow Coma Scale ,pupillary reaction to light and size, reflexes and limb movements, neck rigidity , cranial nerve examination

12. Investigations CT Head Bleeding profile MRI Head Angiography Liver Function Test Serum electrolytes

13. Complications Cerebral Swelling Infection , Seizure , Hydrocephalus Cerebral Ischaemia Cerebral Herniation Amnesia Electrolyte Imbalance

14. Emergency management Airway protection , protection of C-spine IV fluids Head end elevation of bed Pain management and antiemetic Correction of coagulopathy (if necessary) Electrolyte maintenance Diuretics to reduce cerebral edema Anticonvulsants prophylactically

15. Surgical Management Craniotomy and evacuation of hematoma Craniectomy Clipping of Aneurysms Drilling Burrholes over collection and washing it out with normal saline .

16. Post operative Care Admit to ICU & Ventilate Monitor Haemodynamics and Fluid management Monitor ICP & CCP Antibiotics & Anticonvulsants Maintain Temperature Pain management IV fluids till NG feeding Routine care : bowel , bladder ,position and regular chest physiotherapy Repeat CT scan

17. Indications of surgery Volume more than 30 ml Midline shift more than 5 mm Compound depressed fracture of the skull Symptomatic patients Deteriorating GCS score Thickness of hematoma > 1cm in EDH & SDH and >3cm in intracerebellar hematoma

18. References Bailey & Love Short Practice Of Surgery A Manual on Clinical Surgery [S. Das ] Conscise Radiology For Undergraduates Wikipedia

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