INTRACRANIAL HEMORRHAGE powerpoint presentation

hemorrhage

1. INTRACRANIAL HEMORRHAGE DEPARTMENT OF FORENSIC MEDICINE

2. INTRODUCTION MENINGES- The meninges refer to the  membranous  coverings of the brain and spinal cord. There are three layers of meninges, known as the  dura  mater,  arachnoid  mater and  pia  mater . The space between the skull and dura is almost none. There is an artery known as the middle meningeal artery. Pterion is a point where the frontal, parietal,  sphenoid, and temporal meet. This space is known as epidural. The space between the arachnoid and dura is known as subdural space. We have bridging veins that drain to the Dural venous sinus and subarachnoid space. The space between the arachnoid and pia is subarachnoid. Here we have cerebral spinal fluid and many arteries of the circle of Willis . Injury to intracranial blood vessel may manifest as intracranial hemorrhage. If the bleeding is small and thin-layered, it is  called hemorrhage. If it is large and space- occupying, it is called hematoma.

3. INTRACRANIAL HEMORRHAGE 1- Extradural hemorrhage/ Epidural 2- Subdural hemorrhage * Traumatic → A- Acute B-Chronic * Pathological 3- Subarachnoid hemorrhage: 4- Intracerebral hemorrhage/Intraventricular A- Traumatic: Coup injury or Contre -coup B- Pathological

4. EXTRADURAL/EPIDURAL HAEMORRHAGE The dura is a strong and grey-bluish connective tissue membrane, the outer layer of which is firmly attached to the skull and the inner layer merges with the arachnoid . Epidural hemorrhage occurs between the skull and the dura mater ,most commonly involved vessel is middle meningeal artery. Extradural  hemorrhage is caused almost exclusively due   to trauma. At the moment of impact, the skull  moves relative to the dura beneath it, and the dura is stripped from the bone. This produces an empty extradural space at the site of trauma.  It  is the least common type of meningeal bleeding and is seen in one to three percent of cases of head injury. These hemorrhages are rare in the first two years of life due to the greater adherence of the dura to the skull, and the absence of a bony canal for the artery , but are common in adults between 20 to 40 years . Hemorrhage may occur due to fall from a small height, or on being hit by a moving object, or after a minor accident. The initial deformity probably separates the dura from the skull, but as the hemorrhage continues, further stripping of dura occurs with more tearing of the communicating vessels between the skull and the dura and further bleeding.

5. CLINICAL FEATURES: In a typical case, there is a history of head injury which starts the bleeding, and will usually cause temporary unconsciousness . In about 25% of cases ,there is no unconsciousness in the beginning. This is followed by a period of normal consciousness, the "LUCID INTERVAL " of few hours (2 to 4) to a week. Lucid interval is seen only in 30 to 40% cases. Lucid interval is not seen if the injury to the brain is sufficiently great, because of the overlapping of unconsciousness due to the brain injury and due to the pressure of extradural hemorrhage. As the pressure on the brain increases, the patient first becomes confused and may appear to be drunk. With increasing pressure, sleep and coma occur. Increasing weakness occurs in the face or arms on the side opposite to the hemorrhage and spreads to the leg.

6. Pupil is dilated and not reactive to light, usually on the side of hemorrhage. Worsening clinical symptoms are due to cerebral edema or diffuse neuronal injury. Later there is bilateral dilatation and fixation of the pupils, decerebrate rigidity and death. As pressure on the brain increases, brain is displaced and produces stress on structures around third ventricle and midbrain. The usual cause of death is respiratory failure due to compression of the brain stem.   At autopsy , gentle removal of blood may show the break in the vessels and fissured fracture of the nearby skull CHRONIC TYPE: Chronic extradural hematomas are rare and may or may not be associated with fractures of the skull. They are commonly seen in older children and young adults. In these cases symptoms are noted 2 to 3 days after injury. Sudden death may occur after several days. 

7. SUBDURAL HAEMORRHAGE  Anatomy: The arachnoid is a thin, vascular meshwork and is intimately applied to the inner surface of the dura. Subdural space is very narrow and contains a small amount of fluid permitting the thin and tough arachnoid to move relative to the dura. The cerebral veins (bridging veins) cross this space to reach the sinuses. The arachnoid is attached to the dura by venous sinuses and arachnoidal granulations . SDH occurs between the arachnoid and dura mater . This could arise from the tears in the dural venous sinuses or cortical veins, but the most common cause is rupture of bridging or communicating veins.

8. CAUSES OF SDH Subdural hemorrhage is more common than extradural hemorrhage. This occurs in the subdural space between the dura mater and the arachnoid due to : Non-traumatic reason is alcohol intake. Widespread boxing injury Common in children Common in elderly people It is Sickle shape – concave-convex Shaking baby syndrome, which is part of a battered baby syndrome is associated with subdural hematoma.

9. Occurrence: Subdural haemorrhage may occur from relatively slight trauma, often insufficient to cause unconsciousness and usually not producing  fractures of the skull, and may be associated with contrecoup contusions . About 70% occur due to falls and assaults and 25% due to vehicle accidents, and are especially likely to be found in alcoholics, old persons owing to atrophy or shrinkage of the brain and  in children. It may occur in the absence of fracture of the skull or cerebral contusions or other visible brain injury. It occurs after the head impacts a hard surface and the brain is accelerated, which causes tearing of  the parasagittal bridging veins. 

10. FEATURES Death may occur, if the hemorrhage is about 100 to 150 ml. Rapid development of a subdural hematoma will cause compression of the brain stem and secondary brain hemorrhage. It is most commonly supratentorial . It usually appears as thick layers of blood over the superior surface of the brain, which drain down under gravity and cover the whole hemisphere, with a large accumulation in  the middle and anterior fossae. The haemorrhage may remain fluid or may clot into a firm mass. It is essentially venous or capillary and not arterial   Often they accumulate gradually. With slow bleeding, a considerably large subdural haematoma can be tolerated without symptoms or serious side-effects.  Usually, the vessels torn are so small that no main bleeding point can be discovered, either at operation or postmortem .

11.  Types: It is divided into three types according to the time of onset of symptoms after the  injury. (1) In the acute type , hemorrhage occurs immediately and very rapidly after the trauma. ( 2) In the subacute type , the symptoms develop from 2-14 days after injury, due to the pressure of the hematoma. ( 3) Chronic type results from slight trauma in which symptoms appear some weeks or months later.  It can be symptomless or manifest as recurrent headaches, convulsions, altered mental status or focal neurological deficits( aphasia, hemiparesis) Sdh from natural causes is often bilateral while the traumatic variety is usually unilateral.

12. SUBARACHNOID HAEMORRHAGE The space between the arachnoid and the very thin pia is genuine, and is called subarachnoid space . SDH usually arises from the rupture of cerebral arteries or cerebral veins. SAH can be due to trauma/non-trauma but is most commonly due to trauma. Non-trauma is caused due to rupture of a berry aneurysm. Trauma is caused due to rupture of an artery of Willis.  Most common symptom is a headache which is severe, excruciating pain. This is known as a thunderclap headache . It can lead to nausea and vomiting, sudden loss of consciousness, and neurological problems/photophobia

13. Cause of SAH ( 1) Rupture of bridging veins near the sagittal sinus. Focal haemonhages result from force applied to the head, usually accompanied by shaking of the brain and its coverings within the skull . (2) Lacerations and contusions of the brain and the pia arachnoid. (3) Rupture of a Berry aneurysm, which account for 95% of aneurysms that rupture. Blood accumulates rapidly on the undersurface of the brain. With continued bleeding, blood passes along the fissures into the major cisterns and into the fourth ventricle. It may occur due to sudden rise of blood pressure due to emotional stress, such as assault. Alcohol also results in aggressive behavior and a fight and fall, resulting in ruptured aneurysm. Spontaneous hypertensive subarachnoid haemorrhages occur due to rupture of micro aneurysms called Charcot Bouchard aneurysms that form at the bifurcations of sniall intraparenchymal arteries. The aneurysm should be examined at autopsy before fixation in formalin. To demonstrate the aneurysms, a constant stream of water should be poured over the base of the brain, while blunt dissection is made with the handle of a forceps or scalpel . Sometimes, the aneurysm is embedded in the brain surface.

14. In NCCT, the blood will be in the  subarachnoid space. Lumbar puncture can show blood in CSF, This is known as Xanthochromia . It is seen in 4 to 6 hours. It is yellow in color due to bilirubin. For SAH, treatment will be endovascular coiling or clipping. To differentiate between SDH and SAH a water test is done. In the test, water is poured and if the blood gets washed off, this is SDH and if the blood is not washed off, it is SAH . Autopsy: It is mostly venous. In most cases it is diffuse overlying the cerebral haemispheres . Mild or moderate subarachnoid hemorrhage does not produce any significant damage. A slightly yellow discoloration of the leptomeninges is seen as the subarachnoid haemorrhage becomes older. It can be unilateral or bilateral, localised or diffuse. It is usually found over the orbital surface of the frontal lobes, parietal lobes, and the anterior third of the temporal lobes.

15. This can either be a parenchymatous hemorrhage or intraventricular hemorrhage. PARENCHYMATOUS HEMORRHAGE- This refers to haemorrhage in the brain tissue, and may arise directly from the trauma, in which case it usually occurs near the surface. It may be punctate, echymotic or larger ( haematoma ).A single deep-seated parenchymatous haemorrhage is usually due to a disease process, and is often located in the internal capsule, basal ganglia or pons. Multiple punctate haemorrhages may be seen in bleeding disorders, leukaemias , septicaemia,typhus,fat embolism and Wernicke's encephalopathy. Traumatic intracerebral haemorrhages may or may not be associated with skull fracture.Occasionally , it takes several days for the haemorrhage to develop after a traumatic episode. Sudden death is uncommon . INTRACEREBRAL HEMORRHAGE

16. Minute haemorrhages occurring in the brain of a boxer due to repeated punches on the head can lead to mental changes and unsteady gait. This is called punch drunkenness. T his is referred to as chronic traumatic encephalopathy, or "CTE". It is an example of the cumulative damage that can occur as the result of multiple concussions or less severe blows to the head. The condition was previously referred to as "dementia pugilistica ", or "punch drunk" syndrome, as it was first noted in boxers. The disease can lead to cognitive and physical handicaps such as Parkinsonism, speech and memory problems, slowed mental processing, tremor, depression and inappropriate behaviour . It shares features with Alzheimer's disease. CTE has been most commonly found in professional athletes participating in American football, rugby, ice hockey, boxing, professional wrestling, stunt performing, bull riding and other contact sports who have experienced repeated concussions or other brain trauma.

17. Symptoms of CTE generally begin 8-10 years after experiencing repetitive mild traumatic brain injury. First stage symptoms include deterioration in attention as well as disorientation, dizziness and headaches. Second stage symptoms include memory loss, social instability, erratic behaviour and poor judgment. Third and fourth stages include progressive dementia, slowing of muscular movements, impeded speech, tremors, vertigo, deafness and suicidality. Additional symptoms include dysarthria, dysphagia and ocular abnormalities - such as ptosis.

18. Intraventricular Haemorrhage It is a collection of blood within the ventricular system , and may be associated with intracerebral or subarachnoid haemorrhage.However , it can occur as an isolated event, e.g.. severe trauma, vascular malformations of choroida plexus, etc. When massive, intraventricular haemorrhage can be fatal due to impairment of circulation of cerebrospinal fluid and resultant hydrocephalus.

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