Intracranial hemorrhage,intracerebral Hemorrhage,Brain Bleed

Intracerebral Bleed for nurses and medical professionals

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Intracranial hemorrhage
Shemil
Clinical instructor
DMWIMS
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An intracranial hemorrhage is a type of
bleeding that occurs inside the skull.
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Brain Injury
Focal and diffuse brain injury are ways to classify brain
injury.
Focal injury occurs in a specific location.
Diffuse injury occurs over a more widespread area.
It is common for both focal and diffuse damage to occur
as the result of the same even
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FOCAL BRAIN INJURIES
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Classification
Types of intracranial hemorrhage are roughly grouped
into,
1.Intra-axial
2.Extra-axial.
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Intra-axial bleed
Intra-axial hemorrhage is bleeding within the brain
itself, or cerebral hemorrhage. This category includes,
Intraparenchymal hemorrhage(bleeding within the
brain tissue)
Intraventricular hemorrhage(bleeding within the
brain's ventricles) (particularly of premature infants).
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•Intraparenchymal hemorrhage (IPH) is one
form of intracerebral bleeding in which there
is bleeding within brain parenchyma. 
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Causes
•Sympathomimetic drug
abuse
•Moyamoya
disease(constricted blood
vessels)
•Neonatal intraventricular
hemorrhage
•Trauma
•Hypertension
•Arteriovenous
malformation
•Aneurysm rupture
•Intracranial neoplasm
•Coagulopathy(delay in
blood cloting)
•Hemorrhagic
transformation of an
ischemic stroke
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S/S
Hypertension
Fever
cardiac arrhythmias
Nuchal rigidity
Subhyaloid retinal hemorrhages
Altered level of consciousness
Anisocoria(unequal size of the eyes'
pupils)
Nystagmus(involuntary eye movement)
Focal neurological deficits
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Diagnostics
CT
MRI
Angiogram
Carotid duplex(ultrasound to check how well blood is
flowing through the carotid arteries)
Transcranial Doppler(ultrasonography that measure the
velocity of blood flow through the brain's blood vessels by
measuring the echoes of ultrasound waves moving
transcranially)
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IVH
Intraventricular hemorrhage (IVH), also known
as intraventricular bleeding, is a bleeding into the
brain's ventricular system.
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•30% of intraventricular hemorrhage (IVH) are
primary (confined to the ventricular system) caused
by
1.Intraventricular trauma
2.Aneurysm
3.Vascular malformations
4.Tumors
• 70% of IVH are secondary in nature, resulting from
an expansion of an existing intraparenchymal or
subarachnoid hemorrhage. occur in 35% of moderate
to severe traumatic brain injuries.
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Symptoms
 Sudden onset of headache
Nausea and vomiting.
Alteration of the mental state and/or level of
consciousness.
 Focal neurological signs are either minimal or
absent.
 focal and/or generalized seizures may occur.
 
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Diagnostics
•CT
•MRI
•Angiogram
•Carotid duplex
•Transcranial doppler
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EMERGENCY
MANAGEMENT
• Airway managemant
• Expansion of hemorrhage and elevated B.P
• CURRENT RECOMMENDATION :
“ KEEP CEREBRAL PERFUSION PRESSURE
Between 50 to 70 mm Hg “
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ELEVATED ICP
Tracheal intubation and acute hyperventilation
 Mannitol administration
Elevation of head end of bed
 CSF drainage
Control Blood pressure
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Cerebellar hematoma
> 3 cm – evacuation
<1 cm- surgical removal usually unnecessary
1 cm – 3cm : carefully monitored
Monitor
platelet count , PT, PTT to identify coagulopathy
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Extra-axial bleed
Extra-axial hemorrhage, bleeding that occurs within the
skull but outside of the brain tissue, falls into three
subtypes.
 SAH- Subarachnoid hemorrhage
 SDH- Subdural hemorrhage
 EDH-Epidural hemorrhage(extradural hemorrhage)
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SAH
Subarachnoid hemorrhage is bleeding between
the arachnoid and pia mater.
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Causes & Risk factor
TBI
Spontaneously
1.Cerebral aneurysm 
2.High blood pressure
3.Smoking
4.Family history
5.Alcoholism
6. Cocaine use.
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Sign & Symptoms
Sever headache
 Loss of consciousness
 Severe neurologic deficits may develop and become
irreversible within minutes or a few hours.
Sensorium may be impaired & become restless.
Seizures
 Usually, the neck is not stiff initially unless the cerebellar
tonsils herniate.
vomiting
Xanthochromia, yellow-tinged CSF(indicating the presence of
bilirubin in the cerebrospinal fluid  occurs several hours after
bleeding
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Diagnostics
CT.
MRI.
Cerebral Angiography.
Up to 22 percent of aneurysmal subarachnoid
hemorrhages don't appear on initial imaging tests.
Lumbar Puncture.
Repeated Imaging.
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Management
• Medical
Anticonvulsant
Adequate rest
Analgesics and sedatives for headache
Antifibrinolytics( promote blood clotting by
preventing blood clots from breaking down)
Dehydrating measures for brain
LP to relieve severe headache
Surgery – aneurysm ( clipping of its neck ) /
excision of AV malformation
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SDH
Subdural hematoma (SDH) is the
 bleedings between the inner layer of the dura
mater and the arachnoid mater.
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Causes
Traumatic Brain Injury
shaken baby syndrome
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Sign & symptoms
Headache
Confusion
Change in behavior
Dizziness
Nausea and vomiting
Lethargy or excessive drowsiness
Weakness
Apathy
Seizure
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Diagnostics
CT
MRI
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Surgery
There are 2 widely used surgical techniques to treat
subdural haematomas:
•craniotomy – a section of the skull is temporarily
removed so the surgeon can access and remove the
haematoma
•burr holes – a small hole is drilled into the skull and
a tube is inserted through the hole to help drain the
haematoma
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EDH
Extradural haematoma (EDH), also known as
an epidural haematoma, is a collection of blood that
forms between the inner surface of the skull and outer
layer of the dura.
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Causes
AVM
Traumatic Brain Injury
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S/S
Headache.
Nausea or vomiting.
Seizures.
Bradycardia with or without hypertension
Evidence of skull fractures
Cerebrospinal fluid (CSF) otorrhoea or rhinorrhoea.
Alteration in level of consciousness with deterioration
of the Glasgow Coma Scale (GCS) score.
Unequal pupils.
Weakness of limbs
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Treatment :
Craniotomy and clot evacuation
Antibiotics
Anticonvulsants.
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Head end elevation
Monitor BP
Pain Management
Pupil reaction.
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FOCAL
NEUROLOGICAL
SIGNS
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Focal neurologic signs also known as focal neurological
deficits or focal CNS signs are impairments
of nerve, spinal cord, or brain function that affects a
specific region of the body
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1.Frontal Lobe
Hemorrhage
2.Temporal Lobe hmg
3.Parietal Lobe hmg
4.Occipital Lobe hmg
5.Cerebellar hmg
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4
5
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Frontal lobe signs
unsteady gait
Muscular rigidity (hypertonia)
Paralysis of a limb (monoparesis) or a larger area on one side of
the body (hemiparesis)
Inability to express oneself linguistically, described as
an expressive aphasia (Broca's aphasia)
Focal seizures / grand mal or tonic-clonic seizures
changes in personality such as disinhibition, inappropriate
jocularity, rage without provocation; or loss of apathy, akinetic
mutism, general retardation
"frontal release" signs, i.e. reappearance of primitive reflexes
such as the snout reflex, the grasp reflex, and the palmar-
mental reflex
unilateral loss of smell (anosmia)
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Temporal lobe signs
usually involve auditory sensation and memory, and
may include:
deafness without damage to the structures of the ear,
described as cortical deafness
tinnitus, auditory hallucinations
loss of ability to comprehend music or language,
described as a sensory aphasia (Wernicke's aphasia)
amnesia, memory loss (affecting either long- or short-
term memory or both)
complex, multimodal hallucinations
complex partial seizures (temporal lobe epilepsy)
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Parietal lobe signs
Impairment of tactile sensation
impairment of proprioception, i.e. postural sensation
and sensation of passive movement
sensory and visual neglect syndromes, i.e. inability to
pay attention to things in certain parts of the person's
sensory or spatial environment
loss of ability to read, write, or calculate
(dyslexia, dysgraphia, dyscalculia)
loss of ability to find a defined place
(geographical agnosia)
loss of ability to identify objects based on touch
(astereognosia)
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Occipital lobe signs
signs usually involve visual sensation, and include:
total loss of vision (cortical blindness)
loss of vision with denial of the loss (Anton's syndrome)
loss of vision on one side of the visual field of both
eyes (homonymous hemianopsia)
visual agnosias, i.e. inability to recognize familiar
objects, colors, or faces
visual illusions such as micropsia (objects appear
smaller) and macropsia (objects appear larger)
visual hallucinations.
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Limbic signs
(The limbic system is a set of brain structures located on both
sides of the thalamus, immediately beneath the cerebrum)
Damage to the limbic system involves loss or damage to
memory, and may include:
loss or confusion of long-term memory
(retrograde amnesia)
inability to form new memories (anterograde amnesia)
loss of, or reduced emotions (apathy)
loss of olfactory functions
loss of decision making ability
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Cerebellar signs
 signs usually involve balance and coordination, and
may include:
Ataxia
inability to coordinate fine motor activities (intention
tremor), e.g. "past-pointing" (pointing beyond the finger
in the finger-nose test)
inability to perform rapid alternating movements
(dysdiadochokinesia), e.g. inability to rapidly flip the
hands
involuntary horizontal eye movements (nystagmus)
dysarthria
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Brainstem signs
Brainstem signs can involve a host of specific sensory
and motor abnormalities, depending on which fiber
tracts and cranial nerve nuclei are affected.
Spinal cord signs
Spinal cord signs generally involve unilateral paralysis
with contralateral loss of pain sensation
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Pupil Reaction
•Pupil Size and Equality
The normal diameter of the pupil is between 2 and 5
mm, with the average pupil measuring 3.5 mm.
1 mm = 0.1cm
2-5 mm = 0.2 -0.5 cm
Pupil size should be assessed both before and after
the pupil responds to direct light
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Although both pupils should be equal in size, a 1-mm
discrepancy is considered a normal deviation. This
condition is known as anisocoria and is present in 15%
to 17% of the population without any known clinical
significance.
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Pupil Shape
Pupil shape is reported as round, irregular, or oval. The normal
shape of the pupil is round.
 An irregular-shaped pupil may be the result of
ophthalmological procedures such as cataract surgery or lens
implants, and this should be noted on the initial assessment and
confirmed with the patient or family.
 A pupil that is oval in shape may indicate the early
compression of cranial nerve III due to increased ICP, and thus
should be addressed immediately. As ICP is reduced, the oval-
shaped pupil should resolve.
However, if ICP continues to rise or is not treated, the oval-
shaped pupil will become further dilated and will eventually
become nonreactive to light
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•Reactivity to Light
Pupil reactivity is reported as the response or reflex of
each pupil to direct light
The reaction that each pupil has to the light stimulus
should be recorded.
 The speed of pupillary reactivity is recorded as brisk,
sluggish, or nonreactive.
Normally, pupils should constrict briskly in response
to light. A sluggish or slow pupillary response may
indicate increased ICP, and nonreactive pupils are
often associated with severe increases in ICP and/or
severe brain damage.
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A consensual response is any reflex observed on
one side of the body when the other side has been
stimulated.
Consensual pupil reaction.
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•15 normal
•≤8 comatose
•3 unresponsive
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GCS

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Head end elevation @ 30-degree
Head of bed elevation significantly decreases the incidence of
both pulmonary aspiration as well as subsequent development
of bacterial pneumonia & ventilator-associated pneumonia.
The head of a patient’s bed should be elevated to a minimum of
30 degrees or greater, as clinically tolerated, at all times to
reduce patient mortality. patients with closed head injury, the
head of a patient’s bed should be elevated to 30 degrees(will
improve CSF flow) at all times to reduce intracranial pressure
(ICP) and maintain cerebral perfusion pressure (CPP)
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BP
BP should be to decrease SBP to 140 mm Hg, but
not much lower, in acute ICH patients.
High bp and low bp should be monitored and
immediate action must be taken.
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Cheyne stroke respiration
Cheyne–Stokes respiration is an abnormal pattern
of breathing characterized by progressively deeper, and
sometimes faster, breathing followed by a gradual
decrease that results in a temporary stop in breathing
called an apnea. The pattern repeats, with each cycle
usually taking 30 seconds to 2 minutes.
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Increased ICP
The normal ICP is 5 - 15 mmHg. Above 20mmHg are
usually treated.
•Behavior changes
•Decreased alertness
•Headache
•Lethargy
• weakness, numbness, double vision
•Seizures
•Vomiting
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The most definitive way of measuring the
intracranial pressure is with transducers placed
within the brain.
Lumbar puncture
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Brain Herniation
Brain herniation,Cerebral herniation, also referred to
as acquired intracranial herniation, refers to shift of
cerebral tissue from its normal location, into an adjacent
space as a result of swelling from,
head injury
 stroke
bleeding,
brain tumor
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Types
Supratentorial herniation
Uncal (transtentorial)
Central
Cingulate (subfalcine/transfalcine)
Transcalvarial
Tectal (posterior)
Infratentorial herniation
Upward (upward cerebellar or upward transtentorial)
Tonsillar (downward cerebellar)
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