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An intracranial hemorrhage (ICH) refers to bleeding within the brain. Closed intracranial hemorrhage refers to the fact that the skull cavity is not opened or penetrated by an external object or, in the case of skull fracture, by a bone fragment. Bleeding usually results from trauma, such as occurs from a direct blow to the head or during rapid deceleration (i.e., a car crash) in which the brain moves violently against the surface of the skull, causing bruising and tearing of brain tissue. Bleeding may occur into the extradural, subdural, or subarachnoid spaces, into the brain itself, or into fluid-filled chambers within the brain called ventricles (intracerebral). Intracranial hemorrhage is a medical emergency that can result in brain damage and death if not treated promptly.
The extradural area is the space between the inner table of the skull and the outermost lining of the brain (dura mater). Bleeding in the extradural or epidural space (epidural hematoma) accounts for about 2% of all types of head injury. About 85% of those with an extradural hematoma have also sustained a skull fracture. The most common site of the fracture is the temporal bone that lies just above the ear on either side of the head. This fracture can cause tearing of an artery (middle meningeal artery) and result in bleeding and blood clot (hematoma) formation. The bleeding is usually rapid and can cause a sudden increase in pressure in the brain. Left untreated, it can force the brain to move downward toward the spinal canal (herniate) and may result in further neurologic morbidity or even death.
The subdural area of the brain refers to the potential space between the outermost dura mater and the middle layer of the brain (arachnoid). Since this area normally adheres closely to the brain, any bleeding in this area causes immediate and direct pressure on the brain. Approximately 10% to 15% of head injury victims develop subdural bleeding and clots (hematoma). The bleeding can stem from torn arteries, causing rapid bleeding and sudden onset of symptoms, or from torn veins, resulting in slower bleeding and slower onset of symptoms.
When bleeding occurs beneath the arachnoid, it is referred to as subarachnoid hemorrhage. Though less common, subarachnoid hemorrhage can occur in severe head trauma. Ruptured brain aneurysms or arteriovenous malformations can also result in subarachnoid hemorrhage. Blood in the subarachnoid area usually causes generalized brain irritation.
Intracerebral bleeding refers to bleeding into the cerebral hemispheres. These areas of the brain are responsible for alertness, higher level thought processes, and intellectual behavior. Intracerebral bleeding occurs in 2% to 3% of head injury victims. The bleeding typically occurs in the frontal region (frontal lobe) or area above the ears (temporal lobes). This frontal region is primarily responsible for motor functions, insight, and higher intellectual activities. The temporal region is primarily responsible for memory, hearing, and interpretation of speech. Hemorrhagic strokes account for 20% of all strokes and are a frequent cause of intracerebral bleeding, especially in individuals with high blood pressure (hypertension).
Those with (bruising) contusions and/or lacerations of the brain may suffer bleeding from any of these areas, singly or in combination. Bleeding may begin soon after the injury. In some cases, symptoms of intracranial bleeding may not become apparent until sufficient blood collects to displace the brain (space-occupying lesion). The rate of bleeding and the site of bleeding often dictate how quickly symptoms develop. Therefore, the interval between the onset of bleeding and onset of symptoms can range from a matter of hours to months.
Risk: Common causes of these injuries are motor vehicle accidents, falls, assaults, and athletic injuries (particularly football, soccer, and boxing).
Men are twice as likely to sustain ICH as women, and blacks are twice as likely to sustain ICH as whites. Half of all patients with ICH are under age 24 years of age (Olson). Incidence and Prevalence: There are 1.5 million cases of ICH reported in the US annually (Olson). |
Source: Medical Disability Advisor
| History: The clinical presentation varies, based on the location, size, and rate of bleeding. The history may reveal a recent motor vehicle accident, fall, or physical altercation. The individual, family member, or witness may report a loss of consciousness, breathing, or pulse. If alert, individual may have complaints of nausea, vomiting, headache, visual disturbances, sensitivity to light, or neck pain. Other symptoms may include muscle weakness; problems with walking or balance; or problems with memory, confusion, irritability, or seizures. In addition, a past history of alcohol or drug use may be reported. Physical exam: The initial physical exam of an unconscious individual should quickly assess the adequacy of the airway, breathing, pulse, and blood pressure before beginning a more detailed neurological and physical exam. The latter includes an evaluation of level of consciousness, pupil response and vital signs, motor function, reflexes, and memory.
The level of consciousness is the most sensitive indicator of neurological function. Depending on the size and location of the intracranial hemorrhage, changes in the level of consciousness can range from mild lethargy to deep coma. The Glasgow Coma Scale (GCS) is an internationally recognized tool for evaluating level of consciousness and is used to predict outcome. A GCS score of 15 is normal. A GCS score of 3 is the lowest level and represents a deep coma state. The lower the score, the deeper the level of coma and the higher the rates of morbidity and mortality. Vital signs are taken as a baseline and then monitored for changes throughout the recovery. A hallmark of imminent neurological crisis is a loss of the normal autoregulation of blood pressure and pulse called the Cushing reflex. This generally results in a sudden rise in blood pressure and a slowing of the pulse.
Breathing rate and pattern are also evaluated. Irregularities in breathing patterns may indicate pressure from the accumulated blood in any of the respiratory centers scattered throughout the brain.
Pupils are normally equal in size, round and briskly reactive to light. Bleeding may create pressure on the nerves leading to the pupils, producing changes in pupil size, shape, and reaction to light and movement. These changes can be correlated with the severity of bleeding. A sudden dilation of one pupil (anisocoria) is an ominous sign and indicates dangerously high pressure within the brain that requires immediate intervention.
Drooping of one side of the face is a classic sign indicating damage to the nerve pathways supplying facial muscles. Reflexes can be overactive (hyperreflexia). The head and neck may be bruised and swollen. Blood may be present in the ear and behind the eardrum (Battle's sign), or discoloration may occur under the eyes (raccoon's sign). Speech can be slurred or absent (aphasia). If damage has occurred to the frontal lobe behind the forehead, the individual's sense of smell may be impaired (anosmia). Signs of memory failure may be present. Tests: Baseline lab tests include arterial blood gases, complete blood count (CBC), glucose, electrolytes, blood urea nitrogen and creatinine, and drug screen and ethanol (alcohol) levels. Skull x-rays may be ordered to rule out skull fractures. CT of the brain confirms the presence of hemorrhage as well as its size and location. If the CT reveals no blood, a spinal tap (lumbar puncture) may be performed to determine if blood is present in the cerebrospinal fluid. An MRI is not helpful immediately after the injury to diagnose bleeding but is useful after the initial 48 hours to assess the extent of brain injury.
X-rays of the cerebral blood vessels (cerebral angiography) or MRA may be performed if aneurysms are suspected and in other clinically stable vascular disorders. A brain wave test (electroencephalogram, or EEG) may be useful in some cases in which seizures are noted and if the individual's exam and imaging are inconsistent with the clinical presentation. |
Source: Medical Disability Advisor
| Initial management of any individual with head trauma focuses on stabilization of the airway, breathing, and blood pressure. Increased pressure in the brain (intracranial pressure, or ICP) following intracranial hemorrhage is a life-threatening emergency. Neurological status and ICP are usually monitored continuously until stable. Increased ICP may be treated with mechanical hyperventilation to reduce arterial carbon dioxide levels. This decreases blood flow to the brain and hence the ICP. Barbiturates and/or diuretics may also help treat increased ICP.
If increased ICP is related to bleeding into the ventricles of the brain that may interfere with normal reabsorption and circulation of cerebrospinal fluid, a shunt may be placed from the ventricle to the abdominal cavity (ventriculoperitoneal shunt) to drain excess fluid and thereby reduce increased ICP. Clot formations such as epidural or subdural hematomas may require surgical removal (craniotomy with evacuation of hematoma). Any concurrent seizure activity is treated with anticonvulsant medications. Blood pressure, temperature, and respiratory status are carefully monitored. Mechanical ventilators, medications, fluids, and thermal blankets may be used as needed to maintain normal blood pressure, temperature, and respirations. Ruptured aneurysms may need surgical treatment (clipping) either immediately or when the individual is more stable. Subarachnoid hemorrhage is often associated with constriction of surrounding blood vessels (vasospasm), which needs treatment with calcium channel blockers. Later symptoms of convulsions, muscle cramping, and depression are treated with anticonvulsants, antispasticity drugs, and antidepressants, respectively. |
Source: Medical Disability Advisor
| Chances for recovery depend on the location of the bleeding, severity of brain injury associated with the bleeding, and level of consciousness when first seen as measured by the GCS score. Although over 75% of cases of ICH are rated as "mild," 50,000 people die and 100,000 are permanently disabled annually in the US from ICH (Olson).
Recovery may take weeks to months. In adults, most recovery after severe intracranial bleeding occurs within the first 6 months. Smaller improvements may continue for perhaps as long as 2 years. Possible outcomes include memory loss, intellectual impairment, muscular weakness in an arm or leg, or slurred speech, but patterns of recovery vary. The injury may be fatal in cases of damage to vital centers that regulate breathing and blood flow. |
Source: Medical Disability Advisor
| Any unspecified intracranial hemorrhage that has caused physical and mental deficits may need rehabilitation to facilitate recovery. A physiatrist assesses the individual's degree of mental and functional disability and determines the rehabilitation plan. Most individuals with severe head injury (initial GCS < 8) benefit from formal neurorehabilitation. Some individuals with major brain injury and significant mental and functional deficits may be referred to an inpatient rehabilitation facility. Those with less complicated injuries and deficits may benefit from outpatient rehabilitation that can include occupational, behavioral, physical, and speech therapy.
The overall objective for rehabilitation of individuals with traumatic brain injury, including intracranial hemorrhage, is to return them as quickly and as fully as possible to the mainstream of their lives. Doing so requires helping the individual achieve functional recovery and cope with any remaining disabilities. An organized treatment approach from a team of healthcare professionals is necessary to set up a complete treatment program. Goal setting will enhance the effective use of time and resources when treating severe symptoms of intracranial hemorrhage.
Treatment varies for each individual because each head injury results in unique problems. Treatment of the unconscious individual begins with passive range of motion exercises during which the therapist moves joints of the upper and lower extremities. External sounds from a nearby radio or people passing in the hospital hallway may help stimulate even unconscious individuals.
Even when the individual becomes less comatose and more alert, confusion and easy distractibility may occur. Exercises to promote memory return and accomplishment of simple tasks may be helpful. Once the individual regains his or her thinking processes, rehabilitation then focuses on muscular strength, endurance, and flexibility. Muscle imbalance is corrected by traditional methods using techniques to help the muscles and nervous system work together. Group activities may take place in mat classes, wheelchair classes, or in other activities such as volleyball games. Individuals with damage to the nerves supplying the head and neck (cranial nerves) may require rehabilitation of hearing, swallowing, balance, and the muscles that create facial expressions.
The final phase of rehabilitation following intracranial hemorrhage involves helping the individual return to work. Work restrictions or modifications may be needed for those with various levels of head trauma. Participants in the rehabilitation program include physical, occupational, speech, and recreational therapists and social workers. |
Source: Medical Disability Advisor
| Individuals with intracranial hemorrhage are at risk for developing seizures or increased ICP. The latter is a life-threatening emergency that results from bleeding within the skull cavity, swelling of the brain, or an increase in the amount of cerebrospinal fluid. Increasing ICP decreases the flow of blood and oxygen to the brain cells, eventually leading to permanent brain damage, coma, downward displacement (herniation) of the brain toward the spinal canal where vital brain structures are easily compressed, and death. Other complications include rebleeding, damage to nerves supplying the head and neck (cranial nerves), and coma. Narrowing of cerebral arteries near the site of aneurysm or arteriovenous malformation rupture (vasospasm) can complicate subarachnoid hemorrhage. Blood in the subarachnoid space can obstruct absorption and recirculation of cerebrospinal fluid, causing the ventricles of the brain to enlarge. This condition is called hydrocephalus and may require placement of a shunt draining the ventricle into the abdominal cavity (ventriculoperitoneal shunt). Approximately 4% to 30% of individuals with ICH develop a seizure disorder. Chronic headaches persist in 30% to 80% of individuals. About 12% of individuals develop motor disorders, and 44% develop depression (Olson). |
Source: Medical Disability Advisor
| In less severe injury, a worker may temporarily need shorter work hours or more frequent breaks. Time off from work for ongoing rehabilitation and treatment may be necessary. In severe cases, permanent physical and/or mental impairment may prevent individuals from performing previous duties and require adjustment in duties and expectations. |
Source: Medical Disability Advisor
| 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 individual had any trauma to the head or a deceleration injury?
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Did individual receive prompt treatment?
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Does individual or witness report a loss of consciousness, breathing, or pulse? Are there complaints of nausea, vomiting, headache, visual disturbances, sensitivity to light, or neck pain? Does individual complain of muscle weakness, problems with walking or balance, problems with memory, confusion, irritability, or seizures?
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Is there a past history of alcohol or drug use?
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Is individual conscious or unconscious?
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What was individual's initial Glasgow Coma Scale (GCS) score?
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Were arterial blood gases, complete blood count, complete chemistry panel and drug screen, and ethanol levels done? Were skull x-rays, CT of the brain, spinal tap, and later an MRI performed? Was angiography or an EEG done?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Is individual hospitalized and being monitored in ICU?
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Has individual been treated with the appropriate medications, such as barbiturates, diuretics, or calcium channel blockers?
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Was a ventilator necessary? Was mechanical hyperventilation tried?
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Was a ventriculoperitoneal shunt necessary? Was surgical clipping needed?
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Was it necessary to do a craniotomy with evacuation of a hematoma?
Regarding prognosis:
- Is individual active in rehabilitation? Is a home exercise program in place?
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Can individual's employer accommodate any necessary restrictions?
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Does individual have any conditions that may affect the ability to recover?
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Have any complications developed, such as seizures, permanent brain damage, or coma? Did individual have rebleeding, damage to the cranial nerves, vasospasm, or hydrocephalus?
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Source: Medical Disability Advisor
| Olson, David A. "Head Injury." eMedicine. Eds. Joseph R. Carcione, et al. 8 Sep. 2004. Medscape. 7 Oct. 2004 <http://emedicine.com/neuro/topic153.htm>. |
Source: Medical Disability Advisor
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