Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Intracranial Hemorrhage


Related Terms

  • Epidural Hematoma
  • Epidural Hemorrhage
  • Hemorrhagic Stroke
  • Intracerebral Hemorrhage (ICH)
  • Subarachnoid Hemorrhage
  • Subarachnoid Stroke
  • Subdural Hematoma
  • Subdural Hemorrhage

Differential Diagnosis

  • Acute stroke
  • Amyloid angiopathy
  • Anisocoria
  • Anticoagulation in stroke
  • Blood dyscrasias
  • Brain abscess
  • Brain tumor (neoplasm)
  • Cardioembolic stroke
  • Cerebellar hemorrhage
  • Cerebral contusion
  • Cerebral venous thrombosis
  • CNS melanoma
  • Cocaine
  • Delirium
  • Dissection syndromes
  • Epidural hematoma
  • Epilepsy
  • Head injury
  • Herpes simplex encephalitis (HSE)
  • Hydrocephalus
  • Intoxication
  • Moyamoya disease
  • Post-traumatic epilepsy
  • Reperfusion injury in stroke
  • Ruptured cerebral aneurysm
  • Status epilepticus
  • Subarachnoid hemorrhage
  • Subdural empyema
  • Thrombolytic therapy in stroke
  • Vein of galen malformation

Specialists

  • Cardiovascular Internist
  • Emergency Medicine Physician
  • Endocrinologist
  • Internal Medicine Physician
  • Neurologist
  • Neurosurgeon
  • Ophthalmologist
  • Otolaryngologist
  • Radiologist

Comorbid Conditions

Factors Influencing Duration

Factors influencing the length of disability include the number and severity of postoperative complications such as wound infection and adverse reaction to a general anesthetic, extent of the brain injury, individual's mental and emotional stability, individual’s access to rehabilitation facilities, and strength of the individual's support system.

Individuals who experience an intracranial hemorrhage as the result of a traumatic head injury often have other major internal and orthopedic injuries that are also life-threatening and affect their ability to recover. In some cases, the individual may recover fully from the head injury and be disabled by traumatic injuries to some other body system.

Medical Codes

ICD-9-CM:
432.0 - Epidural Hematoma, Non-traumatic; Nontraumatic Epidural Hemorrhage
432.1 - Subdural Hemorrhage; Subdural Hematoma, Nontraumatic
432.9 - Intracranial Hemorrhage, Unspecified; Intracranial Hemorrhage NOS
852.00 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, Unspecified Loss of Consciousness
852.01 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with No Loss of Consciousness
852.02 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness
852.03 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Moderate (1-24 hours) Loss of Consciousness
852.04 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.05 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.06 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration
852.09 - Subarachnoid Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Concussion, Unspecified
852.10 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, Unspecified State of Consciousness
852.11 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with No Loss of Consciousness
852.12 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness
852.13 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Moderate (1-24 hours) Loss of Consciousness
852.14 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.15 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.16 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration
852.19 - Subarachnoid Hemorrhage Following Injury, with Open Intracranial Wound, with Concussion, Unspecified
852.20 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, Unspecified State of Consciousness, Unspecified Loss of Consciousness
852.21 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with No Loss of Consciousness
852.22 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness with Brief (Less than One Hour) Loss of Consciousness
852.23 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Moderate (1-24 hours) Loss of Consciousness with Moderate (1-24 Hours) Loss of Consciousness
852.24 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.25 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.26 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration
852.29 - Subdural Hemorrhage Following Injury, without Mention of Open Intracranial Wound, with Concussion, Unspecified
852.30 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, Unspecified State of Consciousness
852.31 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with No Loss of Consciousness
852.32 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness
852.33 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Moderate (1-24 hours) Loss of Consciousness
852.34 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.35 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.36 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration
852.39 - Subdural Hemorrhage Following Injury with Open Intracranial Wound, with Concussion, Unspecified
852.40 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, Unspecified State of Consciousness
852.41 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with No Loss of Consciousness
852.42 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Brief (Less than 1 Hour) Loss of Consciousness
852.43 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Moderate (1-24 hours) Loss of Consciousness
852.44 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.45 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.46 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Loss of Consciousness of Unspecified Duration
852.49 - Extradural Hemorrhage Following Injury without Mention of Open Intracranial Wound; Epidural Hematoma Following Injury, with Concussion, Unspecified
852.50 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, Unspecified State of Consciousness
852.51 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with No Loss of Consciousness
852.52 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness
852.53 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Moderate (1-24 hours) Loss of Consciousness
852.54 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level
852.55 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level
852.56 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration
852.59 - Extradural Hemorrhage Following Injury with Open Intracranial Wound, with Concussion, Unspecified
853.00 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, Unspecified State of Consciousness, Other and Unspecified
853.01 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with No Loss of Consciousness, Other and Unspecified
853.02 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness, Other and Unspecified
853.03 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Moderate (1-24 Hours) Loss of Consciousness, Other and Unspecified
853.04 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level, Other and Unspecified
853.05 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level, Other and Unspecified
853.06 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration, Other and Unspecified
853.09 - Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Concussion, Unspecified, Other and Unspecified

Overview

© Reed Group
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 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”).

Epidural 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



Causation and Known Risk Factors

Conditions that increase the risk of intracranial hemorrhage include prior stroke, hypertension, excessive anticoagulation, and trauma. The most common cause of traumatic head injury that may lead to intracranial hemorrhage is motor vehicle accidents, especially in teenagers and adolescents, often as a result of alcohol and drug use; the second most common cause of head trauma is falling, especially in the very old and the young (Stock).

Subdural hemorrhage occurs most frequently in individuals with some degree of brain shrinkage (atrophy), such as chronic alcoholics and individuals over the age of 60.

Epidural hemorrhages are four times more common in men than in women (Liebeskind, "Epidural Hematoma").

The prevalence of cerebral aneurysms associated with subarachnoid hemorrhage is higher in men younger than age 40 than in women; after age 40, the prevalence is slightly higher in women (Gershon). From ages 25 to 64, the risk of subarachnoid hemorrhage increases with age in a linear fashion (Gershon). Ruptured aneurysms occur more frequently in women, especially during pregnancy, in those with a family history of congenital arterial defects, and in individuals with a history of cigarette smoking or excessive alcohol consumption (Oman).

Intracerebral hemorrhage primarily results from hypertension, trauma that causes severe bruising of the brain, bleeding tumors, ruptured cerebral aneurysms, leaking of a congenitally tangled vascular complex (arteriovenous malformation, or AVM), and treatment with blood thinners (anticoagulant therapy). Individuals with high blood pressure, African-Americans, Asians, those who abuse cocaine, and those over 55 years of age are more at risk for intracerebral hemorrhage (Liebeskind, "Intracranial Hemorrhage"; Nassisi).

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.

Symptoms of subarachnoid hemorrhage may include a sudden onset of severe headache, nausea, vomiting, stiff neck (nuchal rigidity), fainting, and sensitivity to light (photophobia). Occasionally, an individual may experience warning symptoms that indicate a cerebral aneurysm is leaking or about to rupture, including headache (sentinel headache), weakness on one side of the body, numbness, tingling, speech disturbance, and double vision that does not go away. Some individuals with a ruptured cerebral aneurysm may complain of a severe headache and fall unconscious almost immediately. Others may experience a headache but remain conscious. Still others may suddenly become unconscious without a headache and without warning. Symptoms of arteriovenous malformations may include seizures and cognitive impairment.

Individuals with intracerebral hemorrhage may have a history of hypertension, diabetes, or treatment with anticoagulants. Symptoms of hemorrhage typically come on during the day and include progressive deterioration in consciousness (50% of cases), nausea and vomiting (40% to 50% of cases), headache (40% of cases), seizures (6% to 7% of cases), weakness or paralysis on one side (including face, arm, and leg), slurred speech, difficulty expressing themselves in words (expressive aphasia) or understanding speech (receptive aphasia), disturbances in eye movement, difficulty swallowing (dysphagia), or respiratory depression (Liebeskind, “Intracranial Hemorrhage”).

Physical exam: The examiner may observe changes in the individual's mental status and level of consciousness that may range from clouding of consciousness, confusion, lethargy, obtundation, and stupor to coma. Strength testing may reveal weakness or paralysis on one side. The individual may vomit and have seizures. Speech may be disturbed. Elevated pressure inside the cranium (intracranial pressure [ICP]), and thus in the brain and CSF, may result in pupils that appear unequal in size and react sluggishly to light. If the individual's neurological status is deteriorating rapidly, the examiner must make a quick diagnosis of the type of trauma or hemorrhage based on the most prominent signs and symptoms, so surgical intervention can proceed.

Tests: Computed tomography (CT) is the standard diagnostic tool to quickly determine the presence of skull fractures and bleeding within the skull. If the CT is negative for bleeding, lumbar puncture is performed to determine if blood is present in the CSF. Magnetic resonance imaging (MRI) is not used in the acute phase of injury but is useful after the initial 48 hours to assess the extent of injury to the brain. If a ruptured aneurysm is suspected, a complete vascular study (arteriography) of the carotid and cerebral arteries helps pinpoint the location of the ruptured aneurysm. An angiography may also be performed if subarachnoid hemorrhage is suspected. Additional diagnostic tests may include an electrocardiogram (ECG), chest x-ray, urinalysis, and blood studies (complete blood count [CBC], prothrombin time [PT], erythrocyte sedimentation rate [ESR], blood glucose, electrolytes, and blood type). A diagnosis of subdural hemorrhage/hematoma may require additional tests because symptoms are similar to those of many other diseases and conditions.

Source: Medical Disability Advisor



Treatment

Immediate medical treatment for acute intracranial hemorrhages includes maintaining the airway; assisting respiration if needed; regulating body temperature, blood oxygen level, and blood pressure; establishing intravenous (IV) access to replace fluids and maintain a constant blood sugar level; controlling external bleeding; monitoring ICP; and stabilizing the cervical spine until cervical fracture is ruled out. Maintaining an acceptable ICP with corticosteroids and diuretics is mandatory so that further brain injury does not occur. Setting respiratory parameters so that breaths occur frequently and deeply (hyperventilation) decreases carbon dioxide levels, which lowers intracranial pressure. Once the individual's condition stabilizes, treatment focuses on maintaining the status quo and treating underlying medical conditions and diseases.

Epidural hemorrhage from a torn artery is a life-threatening injury that requires immediate evaluation and treatment. Immediate decompression of the brain is required through a burr hole procedure, craniectomy incision, or opening of the skull cavity (craniotomy). The collection of blood and clots is removed, and active bleeding is stopped. In some cases, bleeding may be arrested by minimally invasive techniques such as endovascular coil embolization (Guglielmi detachable coil system); if an epidural hematoma has formed, it may be removed via closed suction drainage.

If the diagnosis is subarachnoid hemorrhage caused by a ruptured cerebral aneurysm, surgical clipping of the aneurysm is performed through a craniotomy procedure, or vessel occlusion with detachable coils or balloons is performed through an endovascular catheter procedure as soon as the individual's neurological condition permits, in order to prevent rebleeding. Large aneurysms may be surgically tied off (ligated). Until surgery, the individual is kept on absolute bed rest. Fluid balance and nutrition are maintained, and narcotics are given for headache relief, as well as anti-epileptic drugs for seizure control and stool softeners to prevent constipation. The individual is instructed not to strain, especially during bowel movements. If an arteriovenous malformation is accessible, a craniotomy may be performed and the malformation excised to prevent further bleeding.

For individuals with an intracerebral hemorrhage, treatment is generally conservative and supportive and may include anti-epileptic drugs for seizure control, anti-anxiety drugs, and medications to control blood pressure. If increased ICP cannot be controlled medically, an attempt may be made to evacuate an intracerebral hematoma through a craniotomy procedure, but this is often unsuccessful. When the ventricles are blocked or enlarged (hydrocephalus), placing a shunt from the ventricular system in the brain to the abdominal cavity (ventriculoperitoneal shunt) helps decrease ICP by draining excess CSF.

Source: Medical Disability Advisor



Prognosis

Survival following spontaneous bleeding within the brain itself (subarachnoid or intracerebral hemorrhage) is poor if the bleed is large or if the individual is already in a coma when arriving at the emergency room. For those who survive the initial hemorrhage, consciousness gradually returns as the blood is reabsorbed and neurologic function resumes. Many individuals who experience this type of hemorrhage do make a reasonable recovery, but more than 20,000 people die of intracerebral hemorrhage each year (Liebeskind, “Intracranial Hemorrhage”). Intracerebral hemorrhage results in a mortality rate of 40% to 80% within 30 days; half of those deaths happen within the first 2 days (Nassisi). The prognosis for intracerebral hemorrhage involving the brainstem is grim, with 75% of individuals dying within 24 hours of the incident (Liebeskind, “Intracranial Hemorrhage”).

Individuals who have burr hole, craniotomy, or craniectomy procedures to treat intracranial hemorrhage generally recover from surgery. Mortality from intracranial hemorrhage is related more to the severity of the brain trauma, the amount of brain swelling as a result of the trauma, and how deep the individual's coma is at the time of arrival in the emergency room. In general, the deeper the coma upon arrival in the emergency room, the worse the individual's chance of recovering without serious disability.

The prognosis following epidural hemorrhage depends upon the individual’s status prior to surgery and ranges from a 0% mortality rate for individuals who are alert and awake to a 40% mortality rate for those that are comatose (Liebeskind, “Epidural Hematoma”). Epidural hemorrhage caused by arterial bleeding has a death rate ranging from 5% to 50% (Liebeskind, “Epidural Hematoma”).

The prognosis for individuals suffering a ruptured cerebral aneurysm is poor. Nineteen percent of cerebral aneurysms rebleed in the 2 weeks following a rupture; when the aneurysm rebleeds, the death rate climbs to 78% (Oman). Subarachnoid hemorrhage lead to immediate death in 10% to 30% of individuals; 30% to 60% die after they get to the hospital (Gershon). After 1 week, the mortality rate for subarachnoid hemorrhage is 40%; within 6 months, 50% of all individuals with subarachnoid hemorrhage die (Oman). Neurological problems are the outcome for 40% of individuals with subarachnoid hemorrhage who survive (Oman).

Individuals who survive intracranial hemorrhage may have seizures, permanent brain damage, persistent problems with memory loss, dizziness, headache, anxiety, and difficulty concentrating.

Thirty-five percent of individuals admitted to a hospital with a penetrating head injury from a bullet eventually die because their initial injuries are so severe (Vinas).

Source: Medical Disability Advisor



Rehabilitation

The type and duration of rehabilitation for individuals who have survived an intracranial hemorrhage are determined by the extent of brain injury and the rate of recovery of neurological function. Those with less severe brain injuries who are showing significant neurologic recovery can be transferred to a rehabilitation unit as soon as they can leave the acute care setting. Those with more severe brain injuries may require skilled nursing care at home or in a nursing home setting until they regain sufficient neurologic function for a rehabilitation unit. Individuals in a coma require skilled nursing care, most likely in a nursing home setting.

Rehabilitative therapy focuses on restoring the functions required for activities of daily living as much as possible and may include speech, physical, occupational, and cognitive therapy. Individuals with damage to the nerves supplying the head and neck (cranial nerves) may require rehabilitation of hearing, swallowing, maintaining balance, and using the muscles of facial expression. Many individuals require psychological counseling to help them adjust to chronic pain or the loss of mental or physical function. Throughout the recovery and rehabilitation period, families need to be kept informed of their injured family member's progress and limitations. Most families benefit from the support of a social worker to help them work through the emotional, financial, and practical aspects of living with a loved one with a brain injury.

Source: Medical Disability Advisor



Complications

Individuals with intracranial hemorrhage are at risk for developing seizures or increased ICP, a life-threatening situation that results from bleeding within the skull, swelling of the brain, or an increase in the quantity of CSF. Increasing ICP decreases the flow of blood and oxygen to the brain cells and eventually leads to permanent brain damage, coma, downward displacement (herniation) of the brain into the spinal canal, and death. Other complications include rebleeding of the hemorrhage, a second hemorrhage, wound infection, cranial nerve damage, leakage of CSF into the ear or nasal passages (as a result of skull fractures), and coma.

Complications of epidural hemorrhage include an organized collection of blood clots (epidural hematoma) and seizures, as well as persistent headache, dizziness, agitation, depression, fatigue, and difficulties with concentration and memory.

Complications of subdural hemorrhage include subdural hematoma, which are classified according to how much time has passed between the injury and the onset of symptoms. Acute subdural hematomas occur within 4 days of trauma, subacute hematomas occur between 4 and 14 days, and chronic subdural hematomas occur after 14 days.

Narrowing of the cerebral arteries near the site of rupture (vasospasm) is a complication of subarachnoid hemorrhage. Blood in the subarachnoid space can slow the normal flow of CSF and cause the small chambers within the brain containing CSF (ventricles) to enlarge. This condition is called hydrocephalus. A ventriculostomy may be required to drain dangerous amounts of CSF; if the condition becomes chronic, it may require placement of a shunt draining the ventricle into the abdominal cavity (ventriculoperitoneal shunt). Rebleeding of a subarachnoid hemorrhage most frequently occurs within the first day after surgery, at a rate of 4.1% (Oman).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many individuals who survive an intracranial hemorrhage are permanently disabled and unable to return to work. Others may return to work in another capacity or with significant restrictions and accommodations in their workplace. Individuals with permanent brain damage caused by bleeding, infection, or increased ICP may have decreased cognitive ability and may not be able to perform tasks they could before surgery. Individuals who have undergone a craniectomy have portions of their brain unprotected by bone and would risk severe injury if assigned to work in an environment containing moving equipment and similar hazards. Some individuals may suffer damage to the nerves supplying the head and neck (cranial nerves) because of the initial trauma, the bleeding itself, or the surgical procedure required to stop the bleeding. They may experience a number of conditions, including chronic pain, decreased sensation or paralysis in any of the structures above the neck, difficulty swallowing, hearing impairment, visual impairment, or balance disorders that require special restrictions on work duties. Individuals with paralysis or weakness, hearing or visual impairments, or speech difficulties may need retraining in order to return to work. Many individuals recovering from intracranial hemorrhages have changes in their personalities that prevent them from fulfilling the responsibilities of their former positions.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has the diagnosis of intracranial hemorrhage been confirmed by CT?
  • What type of hemorrhage was diagnosed (epidural, subdural, subarachnoid, or intracerebral)?
  • Are other tests needed such as MRI, lumbar puncture if the CT is inconclusive, or angiography if ruptured aneurysm is suspected?
  • Has the location and source of the bleeding been confirmed?
  • Are there any underlying conditions predisposing to intracranial hemorrhage?

Regarding treatment:

  • Has appropriate supportive care, medical therapy, and surgery been instituted? Could individual benefit from second opinion consultation concerning treatment?
  • Does individual have adequate access to rehabilitative services, including physical, occupational, and speech therapy? That is, are such services available? Does individual have access to transportation to the facilities offering the services?
  • Is individual compliant with the prescribed treatment plan with regard to medication, nutrition, exercise, and therapy?
  • Does individual have a support system of family and friends who are well-informed about the individual's condition and limitations? Is additional education or support needed?

Regarding prognosis:

  • Did individual suffer permanent brain damage as the result of trauma, bleeding, infection, or increased ICP?
  • Does individual have unresolved difficulties associated with damage to a cranial nerve such as impaired balance, facial paralysis, or trouble swallowing or hearing?
  • Has individual recovered from the intracranial hemorrhage and neurosurgery but not from injuries to other body systems and organs that were sustained in the same traumatic event?
  • Does individual have preexisting chronic diseases that are preventing recovery from the neurosurgical procedure?
  • Has a brain tumor been ruled out?

Source: Medical Disability Advisor



References

Cited

Gershon, Abner, Robert Feld, and Michael T. Twohig. "Subarachnoid Hemorrhage." eMedicine. Eds. Hugh J. Robertson, et al. 21 May. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/344342-overview>.

Liebeskind, David S. "Epidural Hematoma." eMedicine. Eds. Edward L. Hogan, et al. 10 Mar. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/1137065-overview>.

Liebeskind, David S. "Intracranial Hemorrhage." eMedicine. Eds. Jeffrey L. Saver, et al. 27 Apr. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/1163977-overview>.

Nassisi, Denise. "Stroke, Hemorrhagic." eMedicine. Eds. Richard S. Krause, et al. 5 Feb. 2008. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/793821-overview>.

Oman, Jennifer, and Sean David Lavine. "Subarachnoid Hemorrhage." eMedicine. Eds. Paul L. Penar, et al. 3 Aug. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/247090-overview>.

Stock, Arabela, and Jagvir Singh. "Head Trauma." eMedicine. Eds. G. Patricia Cantwell, et al. 1 Jun. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/907273-overview>.

Vinas, Federico C., and Julie Pilitsis. "Penetrating Head Trauma." eMedicine. Eds. Michael G. Nosko, et al. 27 May. 2009. Medscape. 28 Oct. 2009 <http://emedicine.medscape.com/article/247664-overview>.

Source: Medical Disability Advisor






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