Brain Bleed Basics
Case Report:
65 year old female with PMHx Hypertension presents with bilateral leg weakness onset three days ago. Patient states “my legs feel heavy”. Symptoms are worse with exertion and better with rest. She denies any recent trauma, change in physical activity, bleeding, dietary changes. Patient was seen by her primary physician via tele-health appointment and received a referral for outpatient MRI. Upon MRI patient was found to have an intracranial hemorrhage and was immediately transported to the ED via EMS. On arrival, vital signs were stable. Neurologic exam was unremarkable for any focal deficits. CT scan on arrival demonstrated bilateral acute on chronic subdural hematomas. Neurosurgery was consulted and took the patient to the OR for emergent evacuation of the hematomas.
Subdural vs Epidural Hematoma
|
|
Epidural Hematoma |
Subdural Hematoma |
|
Shape |
Biconvex |
Crescent |
|
Location |
Between skull and dura |
Between dura and arachnoid layer |
|
Blood Vessel |
Middle Meningeal Artery |
Bridging Vein |
|
Crosses Suture Lines |
No |
Yes |
|
Causes |
Most Common: Traumatic head injury with or without skull fracture
|
Most Common: Trauma or translation injury (i.e. whiplash)
Less Common: coagulopathy, diffuse cerebral atrophy (elderly population), dural metastasis, administration of thrombolytics |
|
Presentation |
Short loss of consciousness with return to baseline. The lucid interval is then followed by sudden onset altered mentation: “Talk and Die”
Duration of symptoms: minutes to hours |
Gradually progressing headache, confusion, loss of consciousness, vomiting, ataxia, seizures
Categories: Acute: 1-14 days after onset Chronic: 15+ days |
|
Physical Exam |
Severe: confusion, aphasia, seizures, ipsilateral dilated pupil, Cushing reflex- hypertension, bradycardia, respiratory depression
Mild: vomiting, focal extremity weakness, focal sensory deficits |
|
|
Treatment |
Craniotomy and hematoma evacuation |
Surgery vs observation |
Prognosis:
- Worse outcomes in elderly and delayed surgical intervention
- Intracranial hemorrhage score:
- Components:
- GCS
- Age >80
- ICH volume >30mL
- Intraventricular Hemorrhage
- The more points the patient has the increase 30 day mortality
Resources:
Godoy, D. A., Piñero Gustavo, & Napoli, M. D. (2006). Predicting Mortality in Spontaneous Intracerebral Hemorrhage. Stroke, 37(4), 1038–1044. doi: 10.1161/01.str.0000206441.79646.49
Ma, O. J., Yealy, D. M., Meckler, G. D., Stapczynski, J. S., Cline, D., & Thomas, S. J. (2016) Trauma. In J.E. Tintinalli (Ed). Tintinallis emergency medicine: a comprehensive study guide. (8th ed.) (pp. 1703-1704). New York: McGraw Hill Education.