Intracranial Hemorrhage

What Is an Intracranial Hemorrhage (ICH)?

Intracranial hemorrhage means accumulation of blood inside the skull. It can occur due to head injury or spontaneously. In USA, traumatic head injury is the 2nd-leading cause of death. Spontaneous intracranial hemorrhage is a type of stroke that accounts for about 1 in 10 of all strokes in the United States. In the United States, stroke is the leading cause of disability and 5th-leading cause of death. In this kind of stroke, bleeding occurs inside the skull (“intra-” means “inside,” and “cranial” refers to the cranium, or skull). Like any stroke, an intracranial hemorrhage is a medical emergency requiring immediate care. If you suspect you or someone you know is having a stroke, dial 9-1-1 immediately for prompt transportation to the hospital. Do not drive yourself or someone else to the hospital, as emergency medical service may be administered in the ambulance. Any type of stroke is life-threatening and requires prompt medical treatment for the optimal treatment result.

You can usually spot the signs of a stroke with the acronym/mnemonic “BE FAST”:

  • Balance – Have you lost your balance, felt a sudden headache or "thunderclap" headache, or felt dizzy?
  • Eyes – Is your vision blurry?
  • Face – Is one side of the face numb or drooping? Is it possible to smile?
  • Arm – Do you have feeling in both arms? Can you raise them both up without one drifting down?
  • Speech – Can you speak with slurring words? Are you able to form coherent sentences?
  • Time – Every second counts during a stroke. Call 911 immediately if any of the above symptoms occur.

Intracranial hemorrhages are medical emergencies. As skull is a closed structure, any bleeding inside can raise the pressure. After certain limit this raised intracranial pressure (ICP) will shift the brain or part of the brain from one compartment to another within the skull. This is called brain herniation. Increased ICP and brain herniation are responsible for the headache, vomiting, blurring of vision and if uncontrolled by medicine or surgery will lead to death.

Types of Intracranial Hemorrhages and Their Symptoms:

In Intracranial hemorrhage, blood can accumulate within brain or between its coverings called meninges (Dura, arachnoid and Pia mater). While traumatic hemorrhage can occur in all the layers, spontaneous hemorrhages are more common within brain parenchyma or in the sub-arachnoid space.

There are 4 types of intracranial hemorrhage:

  1. Epidural hematoma: This causes blood to collect outside of the brain between the skull and the outermost covering of the brain. Epidural hematomas are most common after a head injury that causes a skull fracture. Those who suffer from an epidural hematoma usually lose consciousness briefly.
  2. Intracerebral hemorrhage: This involves bleeding inside the brain, and it is the most common type of intracranial hemorrhage and is not usually the result of an injury.
  3. Subarachnoid hemorrhage: These hemorrhages happen when there’s bleeding between the brain and the tissue covering the brain, which is called the arachnoid. Subarachnoid hemorrhage may be caused by head trauma or an intracerebral aneurysm. Usually, the person who has this type of bleeding will vomit and pass out.
  4. Subdural hematoma: This type of intracranial hemorrhage involves a collection of blood on the brain’s surface and is typically the result of a whiplash-type of injury. It is also the type of injury babies experience from shaken baby syndrome, in older adults, and in people who have a history of alcohol abuse.

Causes of Intracranial Hemorrhages:

While most intracranial hemorrhages are the result of a head injury, there are certain activities and lifestyle choices that put you at risk for a head injury. These include heavy alcohol use, high blood pressure, cigarette smoking, illicit drug use (specifically, cocaine), and extreme physical exertion. Patients who have been treated with blood thinners are also at risk for an intracranial hemorrhage.

Diagnosis of an Intracranial Hemorrhage:

Intracranial hemorrhages are diagnosed via a CT scan of the head, which can show brain abnormalities such as swelling or blood clots. In case of trauma, depending on the size and location of the hematoma further management is planned. In case of suspected spontaneous intracranial hemorrhage, upon admission to the hospital, your doctor will evaluate your physical symptoms and rule out any other conditions that can mimic an intracranial hemorrhage. You may need several tests for a concrete diagnosis and treatment plan. If the CT scan shows no signs of a bleed but your doctor suspects a thin subarachnoid bleed, may perform a lumbar puncture (also called a spinal tap) to test the spinal fluid for a definitive diagnosis.

If the preliminary CT or lumbar puncture confirms subarachnoid hemorrhage, a brain angiogram and an MRI will be performed to rule out Brain aneurysms.

Treatment for Intracranial Hemorrhages:

Emergency surgery is required to relieve intracranial pressure. A neurosurgeon must access the area where there is bleeding by drilling into the skull to release the blood or to remove a blood clot. In cases of severe brain swelling, we may have to remove a part of the skull temporarily to relieve pressure. After a few weeks or months, once brain swelling reduces these preserved skull caps can be replaced. Patients may also be prescribed drugs to reduce swelling, such as mannitol, furosemide, steroids, etc. Antiseizure medications will also be administered, as those who have had a stroke are at risk for a seizure.

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