12.11.09 Intracranial haemorrhage

Extradural haematoma

    • Trivial trauma can => EDH in kids

Subdural haematoma

    • Acute SDH normally results from more severe injury than EDH

Subarachnoid haemorrhage

    • Consider the possibility that a traumatic SAH may actually be aneurysmal

      • Which then caused the car crash, fall, etc

    • Perimesencephalic nonaneurysmal hemorrhage (PMH)

      • Subarachnoid blood accumulates around the midbrain

      • From perimesencephalic VEINS

        • => Angiogram -ve

      • Generally very good prognosis

    • Aneurysmal SAH

      • 15-20% mortality at outset

      • 50% 6 month mortality

      • 30% of survivors left with severe disability

      • 1% per day rebleed risk

        • Which have much higher mortality (70-80%)

    • Aneurysm generally continues until the rising ICP stops bleeding by tamponading the brain

    • Management

      • Coil or clip aneurysms to prevent re-bleed

      • Give IV fluids

        • May increase oedema but this risk is outweighed by the benefit of maintaining CPP

      • Nimodipine

        • Dihydropyridine calcium channel blocker

        • Some selectivity for cerebral vasculature

        • Prevents vasospasm (not sure how)

      • Fludrocortisone to prevent salt wasting

      • DON'T diagnose vasospasm until everything else has been ruled out

Pituitary apoplexy

    • Bleeding into/around the pituitary

      • Portal venous system = Unusual blood supply

      • => Susceptibility to haemorrhage

    • Usually occurs in the presence of a tumor of the pituitary

    • Most common initial symptom is a sudden headache, often associated with a rapidly worsening visual field defect or double vision

    • This is followed in many cases by acute symptoms caused by lack of secretion of essential hormones, predominantly adrenal insufficiency

Diffuse axonal injury

    • Reverberation of BRAINSTEM

      • => Initial brainstem responses (respiratory alteration, extension response, etc)

    • 50% have raised ICP

    • Petechial haemorrhages may be seen in white matter tracts or at grey/white interface

Cerebral contusion

    • Focal

      • Often frontal or temporal

    • Maximum swelling is at 4-5 days

      • Delayed deterioration

Cavernous haemangioma

    • Haemangioma that has relatively large blood-filled spaces

    • Do not contain tissue of the organ in which they are situated

    • May bleed spontaneously

Intraparenchymal haemorrhage

    • Management

      • BP control, but only if very high or low

      • Rarely operate

    • Outcome tends to be worse than ischaemic stroke

Cerebral amyloid angiopathy (CAA)

    • Form of angiopathy in which amyloid deposits form in the walls of the blood vessels of the central nervous system

      • Can be caused by the same amyloid protein that is associated with Alzheimer's dementia

        • => More common in people who suffer from Alzheimer's

    • The amyloid material is only found in the brain and as such the disease is not related to other forms of amyloidosis

    • Predisposes blood vessels to failure, increasing the risk of a hemorrhagic stroke


    • AVMs usually cause intraparenchymal bleeds rather than SAH

      • Low re-bleed risk (2-3% per year)

      • Treat with surgery, embolisation, stereotactic radiosurgery

    • Apoplexy = sudden neurologic impairment, usually due to a vascular process

    • HTN tends to cause multiple microaneurysms in brain

      • Only visible under microscope

    • LP can detect RBCs (acutely) or xanthochromia (12 hr later, from bilirubin) after SAH