This document provides an overview of intracranial hemorrhage: - Intracranial hemorrhage is bleeding within the skull that can be classified as either intra-axial within the brain tissue or extra-axial between the brain and skull. Common causes include trauma, hypertension, and vascular abnormalities. - Clinical presentation depends on the location but may include headache, vomiting, altered consciousness, seizures, and focal neurological deficits. Diagnosis is typically with CT scan and sometimes angiography. - Treatment involves stabilizing the patient, treating the underlying cause, and surgery to evacuate mass lesions depending on the size and location of the bleeding. Outcomes depend on the severity but timely management can prevent complications and improve prognosis

1. INTRACRANIAL
HEMORRHAGE
Bibek Kandel
Gandaki Medical College

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

14. Intraventricular hematoma

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