HEMORRHAGING | INTRACRANIAL HEMORRHAGE TREATMENT

INTRACRANIAL HEMORRHAGE

CASE STUDY

CASE STUDY ON 

INTRACRANIAL 

HEMORRHAGE

THE CASE

The case is of a fifty year old male who presented with sudden onset transient loss of consciousness, he was rushed to the the emergency room where he recovered. 

when he recovered he had a severe headache, slurred speech and hemiparesis on his right half of his body. 

A non-contrast CT-scan was done and showed the following.

WHAT IS 

INTRACRANIAL 

HEMORRHAGE ?

An intracranial hemorrhage is a type of bleeding that occurs inside the skull.

 Symptoms include sudden tingling, weakness, numbness, paralysis, severe headache, difficulty with swallowing or vision, loss of balance or coordination, difficulty understanding, speaking , reading, or writing, and a change in level of consciousness or alertness, marked by stupor, lethargy, sleepiness, or coma.

 Any type of bleeding inside the skull or brain is amedical emergency. 

It is important to get the person to a hospital emergency room immediately to determine the cause of the bleeding and begin medical treatment.

TYPES OF ICH

There are four types of 

intracranial hemorrhages

1.Epidural Hematoma

2.Subdural Hematoma

3.Subarachnoid Hematoma

4.Intracerebral Hemorrhage

Epidural 

Hematoma

It typically follows a head injury, and usually with a skull fracture. High-pressure bleeding is a prominent feature.

 If you have an epidural hematoma, you may briefly lose consciousness and then regain consciousness. 

Typically a fracture of the pterion and damage of the meningeal artery.

Subdural 

Hematoma

It’s typically the result of your head moving rapidly forward and stopping, such as in a car accident.

 However, it could also suggest abuse in children.

This is the same type of movement a child experiences when being shaken.

A subdural hematoma is more common than other ICHs in older people and people with history of heavy alcohol use.

Subarachnoid 

Hemorrhage

A subarachnoid hemorrhage is when there’s bleeding between the brain and the thin tissues that cover the brain.

 These tissues are called meninges. The most common cause is trauma, but it can also be caused by rupture of a major blood vessel in the brain, such as from an intracerebral aneurysm.

A sudden, sharp headache usually comes before a subarachnoid hemorrhage. Typical symptoms also include loss of consciousness and vomiting.

Intracerebral 

Hemorrhage

Intracerebral hemorrhage

Intracerebral hemorrhage is when there’s bleeding inside of your brain. This is the most common type of ICH that occurs with a stroke. It’s not usually the result of injury.

A prominent warning sign is the sudden onset of neurological deficit. This is a problem with your brain’s functioning. The symptoms progress over minutes to hours. 

They include:

•headache

•difficulty speaking

•nausea

•vomiting

•decreased consciousness

•weakness in one part of the body

•elevated blood pressure

The Diagnosis

The patient is experiencing the neuroanatomic disorder known as Subarachnoid Hemorrhage.

Blood accumulates within the subarachnoid space, where the major blood vessels of the brain are housed

Blood can be found around the sulci and contours the pia

A non-contrast head CT is used and will detect blood if performed within the first 3 days after aneurysm rupture

The lesion is found on the right hemisphere of the brain and the blood has accumulated in the subarachnoid space where most of the blood vessels of the brain are found which means an aneurysm has ruptured in the brain.

Rupture of an aneurysm is followed by a transient loss of consciousness.

Causes headache which can be described as the worst headache ever felt.

Vascular 

Circulation and 

common areas of 

aneurysm 

ruptures

Blood supply to the brain is normally divided into anterior and posterior segments, relating to the different arteries that supply the brain. 

The two main pairs of arteries are the Internal carotid arteries(supply the anterior brain) and vertebral arteries(supplying the brainstem and posterior brain).

The anterior and posterior cerebral circulations are interconnected via bilateral posterior communicating arteries.

 They are part of the Circle of Willis, which provides backup circulation to the brain. 

In case one of the supply arteries is occluded, the Circle of Willis provides interconnections between the anterior and the posterior cerebral circulation along the floor of the cerebral vault, providing blood to tissues that would otherwise become ischemic

Common places 

where aneurysm 

occurs and ruptures

Saccular aneurysms are most common in the anterior communicating artery (ACoA) or anterior cerebral artery (ACA) in men

Possible signs 

and symptoms 

of Subarachnoid

 Hemorrhage

Meningeal irritation causing

1.photophobia

2.nuchal rigidity

Can also result in

1.focal neurologic deficits

2.impaired conciousness

3.coma

Pathophysiology

Cerebral vasospasm is one of the complications caused by subarachnoid haemorrhage. It usually happens from the third day after the aneurysm event, and reaches its peak on 5th to 7th day.

There are several mechanisms proposed for this complication. Blood products released from subarachnoid haemorrhage stimulates the tyrosine kinase pathway causing the release of calcium ions from intracellular storage, resulting in smooth muscle contraction of cerebral arteries.

 Oxyhaemoglobin in cerebrospinal fluid(CSF) causes vasoconstriction by increasing free radicals, endothelin-1, prostaglandin and reducing the level of nitric oxide and prostacyclin. 

Besides, the disturbances of autonomic nervous system innervating cerebral arteries is also thought to cause vasospasm.

How the 

Diagnosis is 

made.

The patient usually presents with a transient loss of consciousness.

The classic symptom of subarachnoid hemorrhage is thunderclap headache(a headache described as "like being kicked in the head", or the "worst ever", developing over seconds to minutes)

A non-contrast cranial CT will show blood accumulation when performed within the first 3 days.

Management of 

the Disorder

Evaluate all cerebral vessels for aneurysm location (e.g.,angiogram)

Oral or via nasograstric tube nimodipine should be administered to

▪prevent cerebral vasospasm

▪however, it does not angiographically improve vasospasm

▪improve outcomes

Surgical clipping or endovascular coiling

–Wilder Penfield

“The brain is the organ of destiny. It holds within its humming mechanism secrets that will determine the future of the human race.”

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