Intracranial Bleeds

• Intracranial haemorrhage refers to bleeding within the skull.
• There are four types of intracranial haemorrhage: Extradural haemorrhage, Subdural haemorrhage, Intracerebral haemorrhage, and Subarachnoid haemorrhage.
• Extradural haemorrhage occurs between the skull and dura mater and is usually caused by a rupture of the middle meningeal artery in the temporoparietal region.
• Extradural haemorrhage occurs between the skull and dura mater and is usually caused by a rupture of the middle meningeal artery in the temporoparietal region.
• Subdural haemorrhage occurs between the dura mater and arachnoid mater.
• Intracerebral haemorrhage is bleeding into brain tissue.
• Subarachnoid haemorrhage is bleeding in the subarachnoid space.
• Intracerebral haemorrhage and subarachnoid haemorrhage account for 10-20% of strokes.
• Sudden-onset headache is a key feature of intracranial haemorrhage.
• Other symptoms of intracranial haemorrhage can include seizures, vomiting, reduced consciousness, focal neurological symptoms, and impaired speech.
• The Glasgow Coma Scale is a universal assessment tool for the level of consciousness.
• The maximum score on the Glasgow Coma Scale is 15/15, and the minimum is 3/15.
• A score of 8/15 on the Glasgow Coma Scale indicates a need for airway support due to the risk of airway obstruction or aspiration, leading to hypoxia and brain injury.
• Extradural haemorrhage can be associated with a fracture of the temporal bone.
• On a CT scan, subdural haemorrhages have a crescent shape and are not limited by the cranial sutures, able to cross over them.
• A typical history of subdural haematoma is a young patient with a traumatic head injury and an ongoing headache.
• Intracerebral haemorrhage presents similarly to an ischaemic stroke with sudden-onset focal neurological symptoms, such as limb or facial weakness, dysphasia or vision loss.
• Intracerebral haemorrhage can occur spontaneously or secondary to ischaemic stroke, tumours or aneurysm rupture.
• Immediate imaging, such as CT head, is required to establish the diagnosis of intracranial haemorrhage.
• Subarachnoid haemorrhage is usually the result of a ruptured cerebral aneurysm.
• Subdural haemorrhage occurs between the dura mater and arachnoid mater and is caused by a rupture of the bridging veins in the outermost meningeal layer.
• Intracerebral haemorrhage involves bleeding in the brain tissue.
• Subdural haematomas have a period of improved neurological symptoms and consciousness, followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.
• Correcting any clotting abnormality, such as platelet transfusions or vitamin K for warfarin, is crucial in the management of intracranial haemorrhage.
• On a CT scan, subdural haematomas have a bi-convex shape and are limited by the cranial sutures, not crossing them.
• Subdural haemorrhages may occur in elderly and alcoholic patients, due to more atrophy in their brains, making the vessels more prone to rupture.
• Subarachnoid haemorrhage involves bleeding in the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane.
• Intracerebral haemorrhage can occur anywhere in the brain tissue: Lobar intracerebral haemorrhage, Deep intracerebral haemorrhage, Intraventricular haemorrhage, Basal ganglia haemorrhage, Cerebellar haemorrhage, Subarachnoid Haemorrhage.
• The typical history of subarachnoid haemorrhage is a sudden-onset occipital headache during strenuous activity, such as heavy lifting or sex.
• Initial management of intracranial haemorrhage will involve admission to a specialist stroke centre, discussion with a specialist neurosurgical centre to consider surgical treatment, and consideration of intubation, ventilation and intensive care if the patient has reduced consciousness.
• Surgical options for treating an extradural or subdural haematoma include craniotomy, burr holes, and decompressive craniectomy.
• Bloods should include a full blood count for platelets and a coagulation screen.