Cerebral Hemorrhage

Name: Abdulghafour ahmed alandijany Srial no:43000116 Group no :3

Cerebral Hemorrhage

Definition :

Cerebral hemorrhage is bleeding within the skull cavity (cranium) that usually
progresses rapidly and often results in permanent brain damage and death. All bleeding within the skull is called intracranial bleeding, whether the bleeding occurs within the brain itself (intracerebral hemorrhage) or in the area between the brain and the skull (epidural, subdural, and subarachnoid hemorrhage). Three membranes (meninges) protect the brain and spinal cord: the tough outermost membrane (dura mater), the delicate middle membrane (arachnoid), and the innermost membrane lying next to the brain (pia mater). Bleeding within the skull is categorized according to where it occurs, that is, between the layers of the protective membranes (meninges) or in and around the brain itself. Bleeding that occurs between the inner surface of the skull and the outer membrane of the meninges (dura mater) is called epidural hemorrhage. Subdural hemorrhage is bleeding that occurs between the dura mater and the middle membrane of the meninges (arachnoid). Subarachnoid hemorrhage is bleeding that occurs between the arachnoid and the innermost membrane of the meninges (pia mater), in the space that is normally occupied by cerebrospinal fluid (CSF) (Gershon). Intracerebral hemorrhage is bleeding within the brain. Epidural hemorrhage is a life-threatening injury requiring immediate evaluation and treatment. This type of intracranial hemorrhage is caused by a blunt traumatic head injury (e.g., a motor vehicle accident, pedestrian accident, fall, assault, or sports injury) or a penetrating traumatic head injury (e.g., gunshot wound). Epidural hemorrhage is often associated with a skull fracture that tears an artery or sometimes a vein. Blood collects quickly within the skull, putting pressure on the brain. Subdural hemorrhage is also a life-threatening injury requiring immediate evaluation and treatment once symptoms develop. This type of intracranial hemorrhage typically results from a traumatic head injury that causes the brain to move around inside the skull (rotational injury) and become bruised (contused). Bleeding occurs from a torn vein more often than a torn artery, so blood collects slowly within the skull, which can go on for days or weeks before the pool of blood is large enough to compress the brain and cause symptoms. Subarachnoid hemorrhage is the most common type of bleeding following a traumatic head injury. Abrasions, bruises (contusions), andlacerations on the surface of the brain cause bleeding that seeps between the arachnoid and the pia mater that covers the brain. Subarachnoid hemorrhage frequently results from the rupture of a blood vessel in the brain (cerebral aneurysm) that has been weakened

by an outpouching or ballooning present from birth or caused by trauma. Of the 10% to 15% of strokes (cerebrovascular accidents) that involve spontaneous bleeding of a cerebral artery (hemorrhagic stroke) (Nassisi), half are subarachnoid hemorrhages (Oman). Intracerebral hemorrhage is bleeding in or around the brain that occurs with high blood pressure or trauma and as an infrequent complication of anticoagulant medications. The most devastating intracerebral hemorrhages are those that occur in the back of the brain near the brain stem, which controls respiration and other vital functions.

Risk: Conditions that increase the risk of intracranial hemorrhage include prior stroke,
hypertension, excessive anticoagulation, and trauma. The most common cause of traumatic head injury that may lead to intracranial hemorrhage is motor vehicle accidents, especially in teenagers and adolescents, often as a result of alcohol and drug use; the second most common cause of head trauma is falling, especially in the very old and the young (Stock). Subdural hemorrhage occurs most frequently in individuals with some degree of brain shrinkage (atrophy), such as chronic alcoholics and individuals over the age of 60. Epidural hemorrhages are four times more common in men than in women (Liebeskind, "Epidural Hematoma"). The prevalence of cerebral aneurysms associated with subarachnoid hemorrhage is higher in men younger than age 40 than in women; after age 40, the prevalence is slightly higher in women (Gershon). From ages 25 to 64, the risk of subarachnoid hemorrhage increases with age in a linear fashion (Gershon). Ruptured aneurysms occur more frequently in women, especially during pregnancy, in those with a family history of congenital arterial defects, and in individuals with a history of cigarette smoking or excessive alcohol consumption (Oman). Intracerebral hemorrhage primarily results from hypertension, trauma that causes severe bruising of the brain, bleeding tumors, rupturedcerebral aneurysms, leaking of a congenitally tangled vascular complex (arteriovenous malformation, or AVM), and treatment with blood thinners (anticoagulant therapy). Individuals with high blood pressure, AfricanAmericans, Asians, those who abuse cocaine, and those over 55 years of age are more at risk for intracerebral hemorrhage (Liebeskind, "Intracranial Hemorrhage"; Nassisi).

Incidence and Prevalence:Intracranial hemorrhages (all types) account for 20% of all
strokes (Oman). About 4% to 5% of the US population have cerebral aneurysms (Oman). The annual incidence of intracerebral hemorrhage is 12 to 15 per 100,000 people (Liebeskind, Intracranial Hemorrhage). Epidural hemorrhage occurs in 2% of traumatic brain injuries (Liebeskind, Epidural Hematoma).

The annual incidence of subarachnoid hemorrhage is 6 to 16 cases per 100,000 people (Oman), with 80% of all subarachnoid hemorrhages occurring from a cerebral aneurysm (Gershon).

Diagnosis
History: The individual with an intracranial hemorrhage is often unconscious or dazed or
otherwise unable to give a complete medical history. The physician may need to rely on those who were with the individual when the event occurred, as well as friends or family members, to provide information about the individual's current and past medical conditions and diseases. In this case, the history may be inaccurate or incomplete for past injuries, illnesses, surgical procedures, and current treatment of existing chronic diseases. Many individuals with an epidural hemorrhage caused by an arterial tear become unconscious at the trauma scene and then experience a brief period of consciousness referred to as a lucid interval. This is followed by a decrease in the level of consciousness. Other individuals never regain consciousness, and others are awake but dazed. Symptoms include headache, vomiting, and seizures. Individuals with a subdural hemorrhage report having a headache. Drowsiness, confusion, and a decreasing level of consciousness are evident. The individual may remember experiencing a bump on the head or some other head trauma in the recent past, but frequently no obvious traumatic injury has occurred.

Symptoms of subarachnoid hemorrhage may include a sudden onset of severe headache, nausea, vomiting, stiff neck (nuchal rigidity),fainting, and sensitivity to light (photophobia). Occasionally, an individual may experience warning symptoms that indicate a cerebral aneurysm is leaking or about to rupture, including headache (sentinel headache), weakness on one side of the body, numbness, tingling, speech disturbance, and double vision that does not go away. Some individuals with a ruptured cerebral aneurysm may complain of a severe headache and fall unconscious almost immediately. Others may experience a headache but remain conscious. Still others may suddenly become unconscious without a headache and without warning. Symptoms of arteriovenous malformations may include seizures and cognitive impairment. Individuals with intracerebral hemorrhage may have a history of hypertension, diabetes, or treatment with anticoagulants. Symptoms of hemorrhage typically come on during the day and include progressive deterioration in consciousness (50% of cases), nausea and vomiting (40% to 50% of cases), headache (40% of cases), seizures (6% to 7% of cases), weakness or paralysis on one side (including face, arm, and leg), slurred speech, difficulty expressing themselves in words (expressive aphasia) or understanding speech (receptive aphasia), disturbances in eye movement, difficulty swallowing (dysphagia), or respiratory depression (Liebeskind, Intracranial Hemorrhage).

(a) CT scans showing SAH combined with a massive right temporal intracerebral hematoma. (b) Preoperative 3-dimensional CT angiography showing bilateral MCA aneurysms. Ruptured aneurysm on the right side (arrow) was successfully clipped (inset). Clinical deterioration attributable to vasospasm was suspected based on findings of no apparent ischemic lesion on diffusion-weighted MR images (c) and relatively decreased rCBF in the left ACA and MCA territories on Tc-99 m HMPAO SPECT (d)

Physical exam: The examiner may observe changes in the individual's mental status and
level of consciousness that may range from clouding of consciousness, confusion, lethargy, obtundation, and stupor to coma. Strength testing may reveal weakness or paralysis on one side. The individual may vomit and have seizures. Speech may be disturbed. Elevated pressure inside the cranium (intracranial pressure [ICP]), and thus in the brain and CSF, may result in pupils that appear unequal in size and react sluggishly to light. If the individual's neurological status is deteriorating rapidly, the examiner must make a quick diagnosis of the type of trauma or hemorrhage based on the most prominent signs and symptoms, so surgical intervention can proceed.

Tests: Computed tomography (CT) is the standard diagnostic tool to quickly determine the
presence of skull fractures and bleeding within the skull. If the CT is negative for bleeding, lumbar puncture is performed to determine if blood is present in the CSF. Magnetic resonance imaging (MRI) is not used in the acute phase of injury but is useful after the initial 48 hours to assess the extent of injury to the brain. If a ruptured aneurysm is suspected, a complete vascular study (arteriography) of the carotid and cerebral arteries helps pinpoint the location of the ruptured aneurysm. An angiography may also be performed if subarachnoid hemorrhage is suspected. Additional diagnostic tests may include an electrocardiogram (ECG), chest x-ray, urinalysis, and blood studies (complete blood count [CBC], prothrombin time [PT], erythrocyte sedimentation rate [ESR], blood glucose, electrolytes, and blood type). A diagnosis of subdural hemorrhage/hematoma may require additional tests because symptoms are similar to those of many other diseases and conditions.

Treatment
Immediate medical treatment for acute intracranial hemorrhages includes maintaining the airway; assisting respiration if needed; regulating body temperature, blood oxygen level, and blood pressure; establishing intravenous (IV) access to replace fluids and maintain a constant blood sugar level; controlling external bleeding; monitoring ICP; and stabilizing the cervical spine until cervical fracture is ruled out. Maintaining an acceptable ICP with corticosteroids and diuretics is mandatory so that further brain injury does not occur. Setting respiratory parameters so that breaths occur frequently and deeply (hyperventilation) decreases carbon dioxide levels, which lowers intracranial pressure. Once the individual's condition stabilizes, treatment focuses on maintaining the status quo and treating underlying medical conditions and diseases. Epidural hemorrhage from a torn artery is a life-threatening injury that requires immediate evaluation and treatment. Immediate decompression of the brain is required through a burr hole procedure, craniectomy incision, or opening of the skull cavity (craniotomy). The collection of blood and clots is removed, and active bleeding is stopped. In some cases, bleeding may be arrested by minimally invasive techniques such as endovascular coil embolization (Guglielmi detachable coil system); if an epidural hematoma has formed, it may be removed via closed suction drainage. If the diagnosis is subarachnoid hemorrhage caused by a ruptured cerebral aneurysm, surgical clipping of the aneurysm is performed through a craniotomy procedure, or vessel occlusion with detachable coils or balloons is performed through an endovascular catheter procedure as soon as the individual's neurological condition permits, in order to prevent rebleeding. Large aneurysms may be surgically tied off (ligated). Until surgery, the individual is kept on absolute bed rest. Fluid balance and nutrition are maintained, and narcotics are given for headache relief, as well as anti-epileptic drugs for seizure control and stool softeners to prevent constipation. The individual is instructed not to strain,

especially during bowel movements. If an arteriovenous malformation is accessible, a craniotomy may be performed and the malformation excised to prevent further bleeding. For individuals with an intracerebral hemorrhage, treatment is generally conservative and supportive and may include anti-epileptic drugs for seizure control, anti-anxiety drugs, and medications to control blood pressure. If increased ICP cannot be controlled medically, an attempt may be made to evacuate an intracerebral hematoma through a craniotomy procedure, but this is often unsuccessful. When the ventricles are blocked or enlarged (hydrocephalus), placing a shunt from the ventricular system in the brain to the abdominal cavity (ventriculoperitoneal shunt) helps decrease ICP by draining excess CSF.

Prognosis
Survival following spontaneous bleeding within the brain itself (subarachnoid or intracerebral hemorrhage) is poor if the bleed is large or if the individual is already in a coma when arriving at the emergency room. For those who survive the initial hemorrhage, consciousness gradually returns as the blood is reabsorbed and neurologic function resumes. Many individuals who experience this type of

hemorrhage do make a reasonable recovery, but more than 20,000 people die of intracerebral hemorrhage each year (Liebeskind, Intracranial Hemorrhage). Intracerebral hemorrhage results in a mortality rate of 40% to 80% within 30 days; half of those deaths happen within the first 2 days (Nassisi). The prognosis for intracerebral hemorrhage involving the brainstem is grim, with 75% of individuals dying within 24 hours of the incident (Liebeskind, Intracranial Hemorrhage). Individuals who have burr hole, craniotomy, or craniectomy procedures to treat intracranial hemorrhage generally recover from surgery. Mortality from intracranial hemorrhage is related more to the severity of the brain trauma, the amount of brain swelling as a result of the trauma, and how deep the individual's coma is at the time of arrival in the emergency room. In general, the deeper the coma upon arrival in the emergency room, the worse the individual's chance of recovering without serious disability. The prognosis following epidural hemorrhage depends upon the individuals status prior to surgery and ranges from a 0% mortality rate for individuals who are alert and awake to a 40% mortality rate for those that are comatose (Liebeskind, Epidural Hematoma). Epidural hemorrhage caused by arterial bleeding has a death rate ranging from 5% to 50% (Liebeskind, Epidural Hematoma). The prognosis for individuals suffering a ruptured cerebral aneurysm is poor. Nineteen percent of cerebral aneurysms rebleed in the 2 weeks following a rupture; when the aneurysm rebleeds, the death rate climbs to 78% (Oman). Subarachnoid hemorrhage lead to immediate death in 10% to 30% of individuals; 30% to 60% die after they get to the hospital (Gershon). After 1 week, the mortality rate for subarachnoid hemorrhage is 40%; within 6 months, 50% of all individuals with subarachnoid hemorrhage die (Oman). Neurological problems are the outcome for 40% of individuals with subarachnoid hemorrhage who survive (Oman). Individuals who survive intracranial hemorrhage may have seizures, permanent brain damage, persistent problems with memory loss,dizziness, headache, anxiety, and difficulty concentrating. Thirty-five percent of individuals admitted to a hospital with a penetrating head injury from a bullet eventually die because their initial injuries are so severe (Vinas).