NON-

TRAUMATIC
INTRACRANIAL
HAEMORRHAGE

Death due to non

traumatic head injury

DR. Roman Al
Mamun
 NON-TRAUMATIC INTRACRANIAL HAEMORRHAGE

NON-TRAUMATIC INTRACRANIAL
HAEMORRHAGE
Spontaneous Subarachnoid Haemorrhage
The hypertensive haemorrhages result from the rupture of microaneurysms
called Charcot-Bouchard aneurysms that form at the bifurcations of small
intraparenchymal arteries.

Bursting destroys the aneurysm responsible for the haemorrhage and the
adjacent brain tissue.

These aneurysms are seen in increasing number in the arteries of the brain
with age and length of history of hypertension.

The major sites of hypertensive haemorrhages are the putamen (55%),

lobar white matter (15%), thalamus (10%), pons (10%) and cerebellar
cortex (10%).

Bleeding into subaracnoid space is usually the result of rupture of an

aneurysm or rarely an arteriovenous malformation.Aneurysms can be

(1)Developmental (Berry, congenital) (ii) Arteriosclerotic(fusiform) (iii)

Inflammatory (mycotic) and (iv) traumatic.

Berry aneurysm are the most common variety accounting for 95% of the
aneurysms that rupture.
They occur at the bifurcations of major cerebral arteries.

The most common sites that account for about 85% of all ruptured berry
aneurysms are (i) the junction of carotid and posterior communicating
arteries (ii) the anterior communicating artery (iii) the major bifurcation of
the middle cerebral artery in the Sylvian fissure.

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X
Roman Al Mamun
DR.
 NON-TRAUMATIC INTRACRANIAL HAEMORRHAGE

Remaining of the ruptures are in the posterior circulation.

In about 20-30% of cases, there are multiple berry aneurysmal rupture .
Berry aneurysms are also called congenital anerysms but are not present
at birth.

They develop because there is a discontinuity in the smooth muscle of the

media of the carina of arterial bifurcations.

The areterial wall bulges out through the muscular defect to form a thin-
walled secular fundus, composed of only fibrous tissue in which there may
be dditional local degeneration and calcification.

Laminated blood clot and fibrin may be deposited on this attenuated wall.
This insubstantial structure is like an inflated balloon, and ruptures in
activities causing increase in intravascular pressure such as straining while
defecation, lifting heavy weights and sexual intercourse.

Mixed Subarachnoid and CNS Haemorrhages

These mixed haemorrhages result from (i) arteriovenous malformations (ii)
cavernous angiomas (iii)capillary telangiectasis.

Medicolegal Importance of Brain Haemorrhage Ruptured

berry aneurysm and trauma:
Several variation of this exists.
Most commonly, an assault is rapidly followed by signs of subarachnoid
bleeding and subsequently death. When the blow to the head is hard then it
is easy to prove that trauma led to the rupture of berry aneurysm, but when
the blow is not so heavy then the evidence is not so convincing.

The complicating factor is that most assault occurs in conditions when both
the aggressor and victims are physically and emotionally active, so that
adrenal response is likely to be present.
Muscle tone, heart rate and blood pressure increases and it is likely that
raised internal blood pressure in a weak aneurysm is a far more potent
reason for rupture than a blow on the head.
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Roman Al Mamun
DR.
 NON-TRAUMATIC INTRACRANIAL HAEMORRHAGE

A second possibility is that already leaking aneurysm may have a rapidly

developing neurological even behavioral abnormality that led him to conflict
with another person or into dangerous physical position, such as fall or
traffic accident.

However, at autopsy, it may not be able to distinguish the sequence of

events and the aneurysmal rupture may be blamed on the trauma instead
of the reverse.

Subarachnoid Haemorrhage and Alcohol:

A high blood alcohol is said to facilitate bursting of an aneurysm because it
dilates cerebral blood vessels and increases blood flow.

The fibrous wall of an aneurysm is incapable of dilating; neither can major

basal arteries do so to appreciate degree, as they possess little muscle.
However, there is no evidence that alcohol is associated with completely
natural subarachnoid haemorrhage from a ruptured aneurysm, though

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X
Roman Al Mamun
DR.
 NON-TRAUMATIC INTRACRANIAL HAEMORRHAGE

intense physical activity such as sports or coitus certainly does predispose

to rupture.
Moreover alcohol increases the chance to fight producing trauma and
leading to subarachnoid haemorrhage.
Due to unsteady gait, there are always chances of fall.

VERTEBROBASILAR ARTERY INJURY

It has been recognized that blows to the side of the neck can give rise to
fatal subarachnoid bleeding because of tearing or dissection of intrathecal
course of vertebral artery allowing blood to track along the upper part of the
vessel and enter the cranial cavity where the artery penetrates the dural
membrane of the foramen magnum.
Basilar artery and internal carotid artery can also give rise to the syndrome.
The injury is manifested as skin bruising and bleeding into the deep neck
muscles.

Mechanism of vertebral artery trauma:

The vertebral artery is injured due to
(1)overstretching of atlanto-occipital membrane and (ii) impact on muscles
overlying the transverse process of upper cervical vertebrae.

The damage to the vertebral artery occurs at the following places:

1. In the canal within the first cervical vertebrae.

2. Just below the axis, in the space between transverse process of Axis
and Atlas.
3. As it emerges from the exit of the canal in the Atlas.
4. Within the subarachnoid space in the foramen magnum.

The most vulnerable points for trauma are (i) at the penetration of dura (ii)
at exit from Atlas and transverse process and (iii) in osseous canal in Atlas.
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Roman Al Mamun
DR.
 NON-TRAUMATIC INTRACRANIAL HAEMORRHAGE

The demonstration of intracranial bleeding from the vertebrobasilar system

is difficult since while removing the skull and brain at autopsy, the damage
to vessels occurs causing artefactual bleeding.

Autopsy findings:
1. When an external bruise is seen on the side of the neck in a case of fatal
assault such as from a fist, shoe or blunt weapon, the possibility of vetebral
artery injury should be borne in mind.
2. When there are circumstantial evidences suggesting subarachnoid
haemorrhage, vertebral artery damage should be suspected.
3. Usually an external injury is absent but on dissection of neck, there is
bruising of subcutaneous or deep tissues of neck.
4. Radiographs of the anteroposterior and lateral view of the upper cervical
region should be taken. These would reveal fracture of transverse process
of the atlas vertebra, if rarely present.
5. Before search for vetebral artery damage is made, brain should be
examined for berry aneurysms or other vascular haemorrhages in cases of
substantial subarachnoid haemorrhages.
6. Postmortem angiograms can be taken, if facilities exist.
7. When the facilities for radiography and angiogram do not exist, upper
cervical region is dissected to search for vertebral artery damage.
8. Upper cervical spine is exposed by a posterior approach by making
spine free of muscles. The spine should be then sawn till fourth cervical
vertebra. The block of bone is cut out of the floor of the posterior cranial
fossa. This block is decalcified by prolonged immersion in 10% formic acid.
After a week, lateral parts of transverse process can be shaved. The block
is again decalcified for futher one week. The artery can now be exposed by
shaving transverse processes.

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X
Roman Al Mamun
DR.