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Intracranial hemorrhage
- 2. Content • 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 • mainly 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.
- 8. 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 • Mainly due to injury to cortical veins • LOC immediately after trauma • Convulsion is common • Features of increased ICP ,focal neurological deficits or hemiparesis • Head CT shows crescent-shaped deformity
- 11. Subarachnoid hemorrhage • Bleeding into the subarachnoid space • Occur spontaneously, usually from a ruptured cerebral aneurysm. • Severe headache (thunderclap headache), • Vomiting, • Confusion or a lowered level of consciousness, • Seizures. • Lumbar puncture-blood stained CSF , CT scan , Carotid & vertebral angiogram
- 13. 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
- 15. 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
- 16. Investigations CT Head Bleeding profile MRI Head Angiography Liver Function Test Serum electrolytes
- 17. Complications • Cerebral Swelling • Infection , Seizure , Hydrocephalus • Cerebral Ischaemia • Cerebral Herniation • Amnesia • Electrolyte Imbalance
- 18. 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
- 19. Surgical Management • Craniotomy and evacuation of hematoma • Craniectomy • Clipping of Aneurysms • Drilling Burrholes over collection and washing it out with normal saline.
- 20. 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
- 21. 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
- 22. References • Bailey & Love Short Practice Of Surgery • A Manual on Clinical Surgery [S. Das ] • Conscise Radiology For Undergraduates • Wikipedia
- 23. THANK YOU