Traumatic Intracranial Hemorrhage Aaron C. Sigler, DO, MS Neurosurgery Tulane Neurosciences
None Disclosures
Overview Anatomy Epidural hematoma Subdural hematoma Cerebral contusions Outline
Traumatic ICH Overview Hemorrhage within cranium from traumatic injury Epidural Subdural Cerebral contusions: Subarachnoid Intraparenchymal Intraventricular http://www.cohyperbarics.com/tbi-therapy/
Cerebral Vascular Anatomy Common Carotid Anterior Circulation ECA (External) ICA (Internal) C1 cervical segment C2 Petrous segment Caroticotympanic, Vidian artery C3 Lacerum segment C4 Cavernous segment Meningohyposeal trunk, Capsular branches, Inferolateral trunk C5 Clinoid segment C6 Ophthalmic segment Ophthalmic artery, superior hypophyseal artery C7 Communicating segment Posterior communicating artery (PCOMM), anterior choroidal artery Terminal branches: Anterior Cerebral Artery (ACA), Middle Cerebral Artery (MCA)
Vascular Anatomy Posterior circulation Vertebral arteries Posterior inferior cerebellar artery (PICA) Basilar artery Anterior inferior cerebellar artery (AICA) Pontine branches Superior cerebellar artery (SCA) Terminal branches: Posterior Cerebral Artery (PCA)
Vascular Anatomy https://sites.google.com/a/wisc.edu/neuroradiology/anatomy/under-spin/vascular-anatomy
Vascular territories https://sites.google.com/a/wisc.edu/neuroradiology/anatomy/under-spin/vascular-anatomy
Epidural Hematoma (EDH) Epidural space Arterial Direct head trauma Neurosurgical Emergency! Lucid Period Let s play, Where s the Lesion?? Iatrogenic (post surgery) not usually an emergency https://www.mypacs.net/cases/70817609.html
Lucid Period Patient sustains injury Brief LOC Regains consciousness later lapses into unconsciousness talked and died Arterial injury, rapid build up of ICP, brain compression, potential herniation
AMS Focal weakness Exam Findings Focal numbness/tingling GCS lowered Cushing s Triad
Glasgow Coma Scale Maximum 15, Minimum 3 3 Parts: Eyes (4) 4 spontaneous, 3 to speech, 2 to pain, 1 none Verbal (5) 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Motor (6) 6 commands, 5 localizing to pain, 4 withdrawals, 3 flexor posturing, 2 Extensor posturing, 1 none Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet 2:81-4, 1974.
Cushing s Triad Brain compression causes: HYPERTENSION REFLEX BRADYCARDIA RESPIRATORY INSTABILITY Terminal sign of lethal intracranial pressure Herniation imminent or in process
Imaging CT head without contrast: Hyperdense lens-shaped lesion with smooth inner margin underlying skull not crossing sutures (generally) CT C-spine without MRI
Management ABCs stabilization Cervical collar until cleared GCS 8 INTUBATE Correction of underlying coagulopathy Correction of underlying thrombocytopenia ICP control: Mannitol, etc SURGERY!!! Postop: ICP monitoring, seizure prevention, DVT/PE prevention, stress ulcer prevention, PT/OT
Subdural Hematoma (SDH) Subdural space Venous Traumatic, spontaneous, iatrogenic Acute versus Chronic Typically collateral intracerebral injuries (contusions/concussions) Predisposing factors: age, ataxia, coagulopathy, and anti-coagulation
Where s the lesion? Acute SDH
Anatomy of EDH versus SDH https://www.quora.com/why-is-it-that-for-an-epidural-hematoma-they-do-not-cross-the-suture-lines
Exam Findings Focal weakness/numbness/tingling Focal neurologic deficits (speech difficulties, confusion, visual changes, etc) AMS Seizure activity or GTC GCS decreased Cushing s Triad
SDH Kernohan s notch phenomenon Unilateral pupillary dilation coupled with Ipsilateral hemiparesis/hemiplegia Uncal herniation
Imaging CT head without contrast: Sickle shaped area underlying Acute, subacute, chronic CT C-spine without contrast MRI Less useful acutely Axonal injury Structural causes
Where s the lesion?
Acute SDH Management ABCs stabilization C-collar until cleared GCS 8 INTUBATE Cautious reversal of anti-coagulation Seizure prophylaxis and/or treatment Control of ICP: mannitol, hyperventilation, etc Surgical indications: Treatment of symptomatic SDH >1cm at thickest point (>0.5cm in peds) within 4 hrs of injury reduces mortality from 90% to 30% (controversial) Surgical treatment varies Asymptomatic SDH managed expectantly
Subacute/Chronic SDH Management Factors: Age, infirmity Anticoagulants? Size, location, duration Symptoms? Surgical treatment Burr hole(s) versus craniotomy
What is a Membrane? Forms in late subacute to chronic SDH Primitive cell layer that forms to sequester SDH in its removal process Primitive and leaky capillaries Pro-lytic chemical milieu creates vicious cycle that perpetuates SDH
Cerebral contusions Subarachnoid hemorrhages (SAH) Intraparenchymal hemorrhage (IPH) Intraventricular hemorrhage (IVH) Can have any combination of the above and include SDH/EDH https://radiopaedia.org/articles/cerebral-haemorrhagic-contusion
Subarachnoid Hemorrhage (SAH) Subarachnoid space, bleeding of small vessels (capillaries, small arterioles, etc) Trauma versus spontaneous Spontaneous: Ruptured aneurysm (arterial) or AVM Perimesencephalic hemorrhage (venous)
Traumatic SAH Main concern: Blossoming Hold anticoagulation Repeat CT head within 6 hours, and again at 24 hours to confirm stability Conservative management Surgery reserved for expanding life threatening injuries (collateral damage)
Traumatic SAH https://www.researchgate.net/figure/7426978_fig4_fig-6-traumatic-subarachnoidhemorrhage-axial-non-enhanced-ct-shows-high-density
Aneurysmal SAH
Cerebral Angiograms showing various pathology
Intraparenchymal Hemorrhage (IPH) Bleed within the substance of the brain (capillaries/ arterioles) Location highly variable Causes: HTN: controlled and uncontrolled Trauma Structural lesions Arteriovenous malformations (AVMs) Cavernous malformations (cavernomas) Dural venous sinus thrombosis (venous clot) Dural arteriovenous fistula (DAVF) Hemorrhagic tumors (mets, lymphoma, etc) Amyloid angiopathy
ICH Scoring Hemphill et al: The ICH score: A simple reliable grading scale for intracerebral hemorrhage. Stroke 32 (4):891-7, 2001
Diagnostics CT head without contrast: starting point CT C-spine if traumatic CTA with contrast (MRA) CTV with contrast (MRV) MRI brain with and without contrast Diagnostic Cerebral Angiography (DCA)
ABCs Management C-collar if traumatic/neck pain, until cleared SBP control (<140 rapidly) Anticoagulation reversal* Serial imaging Conservative therapy: Transition to PO BP control Re-assess need for anticoagulation Anticoagulate?? Neurology management for hemorrhagic stroke
Management Surgical intervention Varies depending upon pathology Craniotomy for resection
NICO BrainPath
Intraventricular hemorrhage Hemorrhage in ventricles Typically associated with other pathology Rarely isolated issue Casting of the Ventricles Management: Expectant unless obstructive hydrocephalus develops, then EVD in short term possible VP shunt long term Intraventricular tpa (tissue plasminogen activator)
Questions?? Thank you for your attention!