Intracranial Hemorrhage

Intracranial 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), and lacerations 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.
Incidence and Prevalence: Intracranial hemorrhages (all
types) account for 20% of all strokes (Oman).
About

Epidural

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).
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).
Source: Medical Disability Advisor

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.
Fewer than 20% of patients demonstrate the classic presentation of a lucid interval between the
initial trauma and subsequent neurological deterioration. See the image below.

Brain CT scan of 90-year-old man who slipped on a waxed floor. Witnesses reported loss of
consciousness followed by a "lucid interval." Patient arrived to ED unconscious. CT scan
indicates epidural hematoma. Image courtesy of Dr Dana Stearns, Massachusetts General
Hospital.
Following injury, the patient may or may not lose consciousness. If he or she becomes
unconscious, the patient may awaken or remain unconscious.
Other symptoms include the following:

Severe headache

Vomiting

Seizure

Patients with posterior fossa epidural hematoma (EDH) may have a dramatic delayed
deterioration. The patient can be conscious and talking and a minute later apneic, comatose, and
minutes from death.