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TimoKoivisto
TeemuLuoto

Traumatic Cerebral Haemorrhages

Essentials

  • The following types of intracranial haemorrhages can occur either independently or as combinations:
    • epidural haematoma (= extradural haemorrhage; between the cranial bone and the dura mater)
    • subdural haematoma (haemorrhage between the dura mater and the arachnoid)
    • subarachnoid haematoma (haemorrhage beneath the arachnoid, along the brain surface)
    • intracerebral haematoma (haemorrhage inside the brain tissue)
  • Suspect an intracranial haemorrhage when a patient with a head injury
    • has progressive symptoms after the injury (e.g. headache, vomiting, confusion, restlessness)
    • has neurological symptoms down one side of the body, primarily hemiparesis
    • has epileptic seizures
    • decreased level of consciousness An Unconscious Patient.
  • Pupil dilatation in an unconscious patient may be a sign of threatening brain herniation (emergency situation).
  • The diagnosis must be established rapidly - for an unconscious patient immediately. The diagnosis is based on an emergency head CT scan.
  • Consult a neurosurgeon without hesitation regarding the treatment of an intracranial haematoma.

First aid

  • The aim of the first aid is to minimize and prevent the development of additional (secondary) damage to brain tissue.
  • Ventilation (intubation if GCS ≤ 8; blood oxygen saturation target level > 90 %)
  • Circulation (infusion; systolic blood pressure target level > 120 mmHg)
  • Blood transfusions and emergency operations indicated by the injuries
  • Optimization of blood clotting (reversal of anticoagulation, platelet transfusions etc.)
  • Note the cervical spine: rigid cervical collar and immobilization of the spine during transfer.

Diagnosis

  • A CT scan is always required for the establishment of the diagnosis (see Brain Injury and Skull Fracture). When suspecting an intracranial haemorrhage, the patient must not be treated in a facility without this imaging method.
  • The CT scan should be repeated
    • if the patient's condition deteriorates (over 2 points' decrease in GCS or appearing of new neurological symptoms)
    • about 6 hours after the first one, if on the basis of clinical assessment the injury is of at least moderate severity and the first CT was carried out very soon after the injury
    • routinely after about 24 hours in all severe brain injuries (GCS ≤ 8).

Epidural haematoma (extradural haematoma)

  • Typical in children and young people. The mechanism of injury may be mild, and often the patient is conscious at first.
  • Of all patients with brain injury, less than 1% have an epidural haematoma as a CT scan finding.
  • Rapid blurring of consciousness, neurological symptoms down one side of the body, and dilatation of either pupil are signs of serious herniation (increasing size of the haematoma). At this stage the patient needs immediate care and does'nt stand out transportation of any longer duration.
  • The bloodis removed by craniotomy through wide opening. Dural arterial bleeding is the most common reason. In 80% of the cases the haematoma is situated in the temporal lobe.
  • Recovery is rapid and complete, assuming there is no associated brain contusion and no delay in treatment.

Subdural haematoma

  • A haematoma diagnosed in an emergency situation may be really acute or it may be an older one that has turned symptomatic with time.
  • Of all patients with brain injury, about 15-20% have subdural haematoma as a CT scan finding.

Acute subdural haematoma

  • Often in association with brain contusion
  • Caused by arterial or venous bleeding in the contused brain tissue or by rupture of the sagittal sinus
  • The haematoma is large, often crossing over to the other hemisphere.
  • The patients are often elderly or the injury is associated with alcohol use.
  • Anticoagulation therapy and aging increase the risk of bleeding.
  • A large haematoma with symptoms is evacuated by craniotomy.
  • A large share will heal by conservative treatment.
  • The outcome of surgical treatment is also affected by the delay in access to surgery.
  • Mortality is several tens of percents.

Subacute subdural haematoma

  • Becomes apparent 3 days from the injury at the earliest. The delay usually means that the primary injury was mild.
  • The patients are often elderly or they use alcohol in a harmful manner. These factors affect the delay in the establishment of the injury.
  • The haematoma is evacuated by craniotomy.
  • Prognosis is more favourable than in acute subdural haematoma.

Chronic subdural haematoma

  • Symptoms appear only several weeks or even months after the injury.
  • Patients are often elderly who may present with symptoms like confusion, balancing problems or problems with memory. The patients are often on antithrombotic medication.
  • The primary injury is usually a mild one (typically a fall) and often forgotten. The diagnosis is, however, often made in an emergency setting because of rather rapidly developing symptoms (headache, hemiparesis or, in many cases, fluctuating, blurred consciousness) indicating elevated intracranial pressure.
  • A patient with decreased level of consciousness should be operated on immediately.
  • A conscious but symptomatic patient should also be treated on emergency basis.
  • There is no exact threshold limit for the thickness of the haematoma to indicate the need of treatment. In a young patient, a 5-mm thick haematoma may give intense symptoms whereas in an elderly patient, a 1-cm thick haematoma may be completely symptomless due to brain atrophy and may be left unoperated.
  • A symptomatic haematoma with mass effect is usually treated by surgery, even in very old patients.
  • Only a burr hole made in local anaesthesia is required for rinsing and draining a liquefied chronic haematoma.
  • The haematoma is bilateral in 22% of the cases; both sides can be operated on in the same session.
  • Recovery is rapid and usually the symptoms resolve completely.
  • The risk of recurrence is up to 29%.
    • A CT scan should be performed if the patient becomes symptomatic anew with similar symptoms that occurred before the procedure.
    • In recurrent haematomas, burr hole rinsing may be repeated if necessary.
  • Intravascular occlusion of the middle cerebral artery is a new treatment method. Within the next few years, its use is very likely to increase in the treatment of primary and recurrent haematomas in select patients.

Subarachnoid haemorrhage

  • Often occurs diffusely on the convexity and is associated with other intracranial traumatic changes.
  • The bleeding may be located inside the ventricles of the brain.
  • Of all patients with a brain injury, about 10-15% have a subarachnoid haemorrhage as a CT scan finding.
  • In an isolated subarachnoid haemorrhage, the acute treatment is primarily conservative. A communicating (non-obstructive) hydrocephalus requiring treatment may develop at a late stage.
  • A risk factor for poor recuperation after a brain injury

Intracerebral haematoma

  • Usually associated with a diffuse brain contusion. Haematomas are of varying size and sometimes multiple. They should therefore be treated on a case basis.
  • The findings also depend on the mechanism of injury.
    • Falling over causes bleeding particularly in the lower part of the frontal lobe and in the temporal lobe.
  • Treatment requires frequently repeated CT scans and monitoring of intracranial pressure in an intensive care unit.
  • A large, significant haematoma causing pressure symptoms should be evacuated by craniotomy.
  • Prognosis depends on the severity of the brain contusion. An aged unconscious patient has a poor prognosis.

Increased intracranial pressure

  • See Increased Intracranial Pressure.
  • Brain oedema and an increase in the intracranial pressure may be due to any intracranial haematoma, but most often these are associated with an acute subdural haematoma and with brain contusion or with an intracerebral haematoma. Also, haematomas are often associated with oedema caused by a stretch injury in the brain tissue (diffuse axonal injury) which worsens the lack of intracranial space.
  • The intracranial pressure of an unconscious patient is followed-up in an intensive care unit. In addition to the removal of the haematomas, the pressure may be reduced, for example, by postural therapy (upper trunk 30° elevated), administration of mannitol or hypertonic saline solution, by hyperventilation, by sedation and by cerebrospinal fluid drainage.
  • When all the available methods for decreasing the intracranial pressure have been used, an extensive decompressive craniectomy may be performed in extreme cases Decompressive Craniectomy for High Intracranial Pressure in Traumatic Brain Injury.
  • Prophylactic antiepileptic medication (e.g. fenytoin or levetiracetam) should be used short-term (for about 1 week) in patients with moderate or severe brain injury.

References

  • Stippler M, Smith C, McLean AR et al. Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J 2012;29(7):528-32. [PubMed]
  • Brown CV, Zada G, Salim A et al. Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 2007;62(6):1339-44; discussion 1344-5. [PubMed]
  • Luoto T. Clinical assessment of acute mild traumatic brain injury [Thesis]. Tampere University Press: Acta Universitatis Tamperensis 1940. Acta Electronica Universitatis Tamperensis 1424http://urn.fi/URN:ISBN:978-951-44-9466-6
  • Bajsarowicz P, Prakash I, Lamoureux J et al. Nonsurgical acute traumatic subdural hematoma: what is the risk? J Neurosurg 2015;123(5):1176-83. [PubMed]
  • Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 1991;74(2):212-8. [PubMed]
  • Ivamoto HS, Lemos HP Jr, Atallah AN. Surgical Treatments for Chronic Subdural Hematomas: A Comprehensive Systematic Review. World Neurosurg 2016;86():399-418. [PubMed]
  • Servadei F, Murray GD, Teasdale GM et al. Traumatic subarachnoid hemorrhage: demographic and clinical study of 750 patients from the European brain injury consortium survey of head injuries. Neurosurgery 2002;50(2):261-7; discussion 267-9. [PubMed]
  • Yang Y, Zheng F, Xu X et al. Levetiracetam Versus Phenytoin for Seizure Prophylaxis Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis. CNS Drugs 2016;30(8):677-88. [PubMed]
  • Catapano JS, Nguyen CL, Wakim AA et al. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Front Neurol 2020;11():557233. [PubMed]