Intracranial Hemorrhage: Evaluation and Summary

00:01 So, now, let’s talk about how we evaluate patients who present with a new intracranial hemorrhage. We have high suspicion of new ICH in patients presenting with a new focal neurologic deficit, a new severe thunderclap headache or evidence of increased ICP, symptoms like nausea, vomiting, or impaired consciousness. Those three presenting symptoms should raise suspicion for a new mass lesion in the brain and all patient should undergo stat noncontrast head CT to evaluate for hemorrhage. When there is high suspicion of hemorrhage or stroke-like presentation, we also consider blood draw for PT, PTT, platelet count, sometimes fibrinogen or type and cross if we’re concerned about a systemic hemorrhage and an intracerebral hemorrhage complication. A first question on the patient’s head CT is, “Is hemorrhage present?” If hemorrhage is not present, we’re looking for some other underlying mass lesion or ischemic stroke as the cause of that patient’s presentation. If the hemorrhage is present, then our next question is, “Is the patient on anti-platelet or anti-coagulant therapy?” And that’s going to determine our level of monitoring and the degree to which we need urgency for those patients.

01:18 In patients who are on anticoagulation, we have high concern that that initial hemorrhage could propagate and so the patient should have interventions to mitigate that risk and lower the risk of propagation of hemorrhage. We will administer cryoprecipitate with or without vitamin K depending on the type of anticoagulant and the goal is to reduce propagation or expansion of patient’s hemorrhage. Those patients will be evaluated with an early second noncontrast head CT to evaluate for ICH growth.

01:49 If there is subsequent growth of the hemorrhage, patients may be considered for surgical intervention, and if not, those patients continue to be followed clinically or with repeat imaging to evaluate their status over time. And following the second head CT, consensus decisions often with neurosurgical input are discussed and considered regarding the need for surgical management or medical therapy. In patients who are on anti-platelet therapy, there really is no reversal agents available for those patients and so they should be monitored closely in or outside an ICU setting depending on the level of symptoms and urgency about their comorbidities and we consider early repeat head CT and 6, 12 or occasionally 24 hours for those patients. And then following evaluation with the second head CT, subsequent management decisions are made. If there is early propagation or expansion, we may consider closer monitoring or the need for surgical intervention in rare cases but the vast majority of patients would be monitored closely.

02:50 And then in patients not on anticoagulant and anti-platelet therapy, we still need to evaluate the risk of expansion of the hemorrhage and so those patients typically undergo a second head CT in the first 12 to 24 hours after their initial scan to evaluate for any risk of ongoing or rebleeding. So let’s quickly summarize some of the key things we’ve learned about the types of intracranial hemorrhages. First, intraparenchymal hemorrhages. These hemorrhages are located inside the brain. Some mechanisms include hypertension, high blood pressure, trauma, vascular abnormalities, tumor or recent stroke. The source is both arterial or sometimes venous for these patients.

03:33 The shape is typically a round lesion, either in the deep subcortical areas of the brain or out in the lobes. And these patients present with a focal neurologic deficit, often with headache but not universally and sometimes can present with symptoms of increased intracranial pressure particularly with large hemorrhages that are resulting in compression of the ventricular system. Intraventricular hemorrhage. This is a hemorrhage located within the ventricular system. There are a number of mechanisms. This can occur primarily with primary IVH or secondary to subarachnoid or intraparenchymal hemorrhage. The source can be arterial or venous from an underlying venous vascular abnormality.

04:14 The shape typically conforms to the ventricles and you can see that here in this non-contrast head CT where hemorrhage is taking in each of the areas of the lateral and third ventricle. And the presentation is acute onset of typically headache and symptoms of ICP. These patients have nausea, vomiting, severe headache, ultimately progressing to loss of consciousness in severe cases. Subarachnoid hemorrhage. This is hemorrhage located between the arachnoid and the pia mater in that subarachnoid space. Mechanisms include trauma, ruptured aneurysms or other arteriovenous malformations. The source is predominantly arterial for this hemorrhage. The shape, the hemorrhage tracks along the sulci and into the fissures and you can see that here with hyperdense hemorrhage tracking along the course of the blood vessels, the ACA, MCA and even out over the tentorium. And the presentation is typically an acute, severe, worst headache of the patient’s life, a thunder clap headache. Subdural hemorrhages.

05:21 These hemorrhages are located between the dura and the arachnoid and the mechanism is primarily trauma, falls, motor vehicle accidents, or other trauma. The source is venous. These hemorrhages occur because of rupture of bridging veins that course in that subdural space and result in leaking of blood into the subdural space with development of subdural hemorrhage. On imaging, we see a crescent-shaped lesion that extends beyond the suture lines of the brain and patients present with new focal neurologic deficit and progressive development or decline in neurologic function and typically headache. And then lastly, epidural hemorrhages. The location of epidural hemorrhages, these are between the dura and the skull. This typically occurs after trauma. One of the vessels we worry about with epidural hemorrhages is the middle meningeal vessel which is in an at-risk area just beneath the skull of the brain and can be irritated or damaged or ruptured as a result of trauma, resulting in the development of an epidural. The source is predominantly arterial in these patients. The shape on imaging is a lens shape as you see here, not crossing suture lines, and patients present with acute altered mental status but often with a lucid interval, initial neurologic symptoms followed by normalization then progressive decline, and this is a medical and neurosurgical emergency.