FRCA Notes

Intracranial Haemorrhage

Resources

  • Approximately 10% of stroke is due to intracranial haemorrhage (ICH)
  • It is associated with:
    • High short-term mortality; 30-day mortality as high as 30-40%
    • Significant long-term disability; only 20-25% are able to function independently at six months

Primary ICH (85%)

  • Chronic hypertension (60%)
  • Cerebral amyloid angiopathy (30%)

Secondary ICH (15%)

  • Trauma
  • Aneurysms e.g. aneurysmal subarachnoid haemorrhage
  • Vasculitis
  • Vascular malformations
  • Haemorrhagic conversion of infarct
  • Substance abuse

Extradural haematoma

  • Blood accrues between the periostium and the dura
  • Usually due to a tear in the middle meningeal artery or dural venous sinuses
  • Often associated with a fracture
  • Lentiform appearance on CT
  • Classically there is an intial loss of consciousness, followed by a lucid period, followed by further deterioration in consciousness

Subdural haematoma

  • Blood accrues between the pia and arachnoid mater
  • Usually due to a tear of bridging veins in the subdural space
  • Crescent-shaped appearance on CT
  • Acute SDH may require early evacuation
  • Chronic SDH occurs in the elderly with even trivial injury and may be managed conservatively

Intracerebral (intraparenchymal) haematoma

  • Blood accrues amongst the brain parenchyma itself
  • Often due to trauma although may arise due to the effects of anticoagulation

± Intraventricular haemorrhage

  • Occurs in up to 45% of ICH patients, usually secondary to bleeds in the basal ganglia or thalamus
  • The presence of IVH increases mortality significantly, while the intraventricular volume is an independent predictor of poor outcome

Bloods & simple investigations

  • FBC; anaemia or thrombocytopaenia is associated with poor outcome and haemorrhagic expansion
  • U&E; AKI associated with poor outcome
  • Glucose; hyperglycaemia associated with poor outcome
  • CRP
  • Clotting studies ± specific tests for anticoagulants e.g. anti-Xa assay, DOAC concentration
  • Troponin; elevated levels associated with increase mortality

  • ECG ± TTE
  • Urine toxicology screen if suspicion of drug-induced cause
  • Pregnancy test in female patients to exclude PET (/HELLP)

Imaging

  • CT head ± CT angiography ± CT venogram
    • Serial CTs may be of benefit
  • MRI head ± MR angiography
  • DSA

Medical

Organ system Management steps
Respiratory Ensure adequate oxygenation
May need invasive ventilation if low GCS
Cardiovascular Target SBP 130-150mmHg within 2hrs of ICH onset
Maintain CPP
Neurological Admit to specialist stroke unit or NICU
No routine anti-seizure drug prophylaxis
Treat seizures if they arise
Neuroprotective measures
Gastrointestinal Blood glucose 5-10mmol/L
SALT review
Haematological Rapid reversal of anticoagulation
Platelets if going to theatre and on anti-platelets
VTE prophylaxis from 24hrs
Microbiological Maintain normothermia
Treat hyperthermia
Institutional Consider transfer to neurosurgical centre

Surgical

  • Consider EVD in those with hydrocephalus or IVH
  • Consider ICP monitoring in those with ICH and reduced consciousness
  • Consider minimally invasive haematoma evacuation i.e. burr-hole craniotomy ± thrombolysis for supratentorial haematoma, as it improves outcome vs. medical management alone
  • Consider craniotomy and evacuation for posterior fossa haemorrhage or acute supratentorial haematoma e.g. acute SDH
  • Consider decompressive craniectomy in the management of refractory raised ICP

  • Intra-operative management reflects standard intra-operative care in neurosurgery
  • The overriding priority in the patient with intracranial haematoma is maintenance of cerebral perfusion, by:
    • Employing standard methods to reduce ICP
    • Raising MAP to achieve a suitable CPP

Cardiovascular

  • Intra-arterial blood pressure monitoring is essential, with transducer set at the level of the external auditory meatus to accurately gauge the intracerebral MAP
  • Assume ICP 20mmHg or more and maintain a suitable MAP throughout

Neurological

  • Depending on the rate of haematoma development, there may be rapid rise in ICP
  • The poor compliance of the skull and dura can lead to impaired perfusion due to low CPP, with eventual coning
  • Consider use of osmotic agents to temporarily lower ICP
  • Typically require post-operative ventilation if raised ICP or obtunded pre-operatively