Intracranial Hemorrhage

1 What is Intracranial Hemorrhage?

Intracranial hemorrhage is bleeding inside the skull of the head. The collection of blood compresses the brain that causes serious complications and death if not treated immediately. 

The brain is well protected by the skull, meninges, and the cerebrospinal fluid; they completely surround the brain, so the inside of the head is a completely enclosed space. Therefore, any swelling like blood caused by bleeding inside the head compresses the brain. 

What is a Hemorrhage?

Intracranial hemorrhage is usually a consequence of injuries like concussions, repeated blows to the head, or even shaken baby syndrome, but can also be caused by non-traumatic causes such as ruptured aneurysms in hemorrhagic stroke

Compression of the brain often results in life-threatening damage. Intracranial hemorrhage requires immediate medical treatment, often requiring surgery to remove the collected blood and relieve pressure on the brain.

2 Symptoms

Intracranial hemorrhage symptoms may be evident immediately after sustaining a serious head injury, or may happen in several days or weeks. Intracranial hemorrhage may cause the following signs and symptoms:

  • Headaches of increasing intensity
  • Vomiting right after or sometime after the injury
  • Progressive loss of consciousness, starting from drowsiness
  • Dizziness
  • Confusion regarding time, place or current situation
  • Slurring of speech
  • Unequal size of pupils
  • Increasing blood pressure 
  • Having lucid intervals, or temporary improvement of consciousness after the injury, after that the condition deteriorates again

Symptoms often worsen due to increasing amount of blood filling the space between the skull and the brain, causing the following:

  • Having seizures 
  • Lethargy
  • Losing consciousness

Because intracranial hemorrhage can cause death, having any of the mentioned symptoms requires emergency medical treatment. You need to have urgent medical attention if you lose consciousness or experience symptoms of suspected intracranial hemorrhage after sustaining a blow to the head. 

Note that some signs and symptoms of intracranial hemorrhage do not always happen immediately after the injury. Therefore, individuals who sustained head injuries but looked apparently fine must be closely monitored for several days; if warning signs or symptoms occurred, they must be brought to a medical facility immediately.

If you experienced head injury, ask someone to look after you. Note that head injuries may cause memory loss, so you are likely to forget that injury and miss warning signs. You also need to undergo close monitoring.

3 Causes

Intracranial hemorrhage is often caused by automobile accidents, falls, ski injuries, sports injuries, concussions, assaults and motorcycle and bicycle accidents. Because it develops inside the head, intracranial hemorrhage can happen even if there is no visible wound, bruise or swelling. 

Older adults, particularly those prescribed with blood thinners, are more vulnerable and can have intracranial hemorrhage with mild head trauma. 

There are three layers of membranes surrounding the brain. Each of these membranes contains blood vessels. Intracranial hemorrhage happens when trauma or an aneurysm damages a blood vessel in these membranes. 

The leaking blood collects and forms a swelling called hematoma, which compresses the brain. The brain is very sensitive to pressure and swelling inside the head. Compression can physically destroy brain neurons or cut off blood supply, causing serious complications and permanent brain damage. 

Intracranial hemorrhage is divided into three, classified according to the involved membranes covering the brain:

         This is caused by bleeding in the dura mater, the thickest and outermost membrane. Usually, the veins are ruptured and form a hematoma that compresses the brain. The condition becomes progressively worse as the hematoma continues to enlarge, which can result in death.

Subdural hematomas are further divided into the following, depending on the onset of symptoms:

  • Acute subdural hematoma is the most dangerous and characterized by rapid development of symptoms immediately after the injury. It is generally caused by severe head injury.
  • Subacute subdural hematoma takes some time for symptoms to develop after the injury. It can take days or even few weeks.
  • Chronic subdural hematoma is caused by much slower bleeding and often less severe. It can take several weeks after the injury for symptoms to appear. In many cases, the patient cannot recall having the injury.

All of these types of subdural hematoma can result in brain damage, which can become permanent if not addressed quickly. Therefore, you need urgent medical attention once signs and symptoms appear.

Subdural hematoma is more likely in the following individuals:

  • Those who abuse alcohol
  • Those who take anticoagulants, like aspirin, on a daily basis
  • Elderly individuals
  • Epidural hematoma

         An epidural hematoma occurs when there is bleeding between the dura mater and the skull. Epidural hematoma often involves a ruptured artery, and the pooled blood forms a mass that compresses the brain. Most patients with epidural hematoma become drowsy or comatose from the moment of trauma, though some remain conscious. 

         An epidural hematoma is life threatening and requires urgent medical treatment. 

  • Intraparenchymal hematoma

         This is caused by bleeding inside the brain hemispheres, rather than bleeding in the membranes surrounding the brain. It is as serious as other types of intracranial hemorrhage. A head injury often results to multiple severe intraparenchymal hematomas. 

Traumas that cause intraparenchymal hematomas also cause the so-called white matter shear injuries – which are simplified as subjecting the brain to shearing force. 

This causes the axons to tear off from neurons (diffuse axonal injury), cutting off the brain from the rest of the body. Diffuse axonal injury is very common and often results in devastating complications, causing the patient to undergo coma and persistent vegetative state. 

4 Making a Diagnosis

Making a diagnosis of intracranial hemorrhage is done by performing several imaging tests.

Intracranial hemorrhage requires urgent medical attention, and doctors often presume it when the patient progressively loses consciousness after a head trauma.

Imaging tests like magnetic resonance imaging (MRI) and computerized tomography (CT) scan can easily determine the position and size of hematoma

  • CT scan – uses a sophisticated X-ray machine guided by a computer, which creates several X-ray scans to produce detailed images of your brain quickly and with little preparation. 
  • MRI – uses a powerful giant magnet and radio waves to create detailed computerized images of your brain. However, it requires some preparation that is not desirable for urgent situations like intracranial hemorrhage. It also takes longer to perform an MRI, and the machine itself is not widely available.

5 Treatment

Intracranial hemorrhage requires urgent treatment. Surgery is the only way to remove hematomas inside the head. When imaging tests pinpointed the location of the hematoma, your doctor may recommend or do the following surgical procedures:

  • Surgical drainage – the surgeon drills a small hole in your head and uses suction to remove the blood. This is preferred for localized hematomas with little blood clotting
  • Craniotomy – this procedure requires creating a larger opening in your skull to remove blood. This is the option for large hematomas with lots of clotted blood or to repair tears in the membranes of the brain if present. 

If hematomas are very small and do not cause signs or symptoms, the doctor may recommend not removing them.  

Recovery

After surgery, the doctor may prescribe anticonvulsant medications to prevent seizures, which is a common complication. The medications may need to be taken for up to a year after the head injury, or even longer if seizures continue. 

Surgery for intracranial hemorrhage may cause the following side effects:

Recovering from intracranial hemorrhage may take a long time, particularly for cases with sustained damage to the brain. Some patients cannot fully recover. If needed, the doctor may prescribe occupational and physical therapy.

Some cases of hematomas do not undergo immediate medical treatment due to delayed onset of signs and symptoms, which increases the risk of serious complications. For such cases, the doctor may order close monitoring for neurological changes, tests for changes in pressure inside the head, and repeated head CT scans.

For patients regularly taking blood thinners like warfarin or aspirin, the doctor may prescribe treatments like a transfusion of fresh frozen plasma or administer vitamin K to reverse effects of these medications and reduce the risk of further bleeding.

6 Prevention

Minimizing head injuries is your best chance to prevent having intracranial hemorrhage:

  • Protect young children by properly using car seats, block stairwells, secure heavy furniture to the wall, pad countertops and edges of tables, and keep children from climbing on unsafe objects.
  • Always wear seatbelts and make sure the car’s occupants does the same as well. Make sure kids are buckled up too. 
  • Wear helmet when playing contact sports. Make sure to wear a helmet when doing things like riding a bicycle, motorcycling, skiing, horseback riding, skating, skateboarding and snowboarding.

7 Lifestyle and Coping

Lifestyle modifications are necessary in order to cope with intracranial hemorrhage.

Recovery from intracranial hemorrhage may take time, so you need to have lots of patience. Many patients experience big leaps of recovery in the first six months and then smaller gradual improvements for up to two years. 

One of the most important things during recovery is communicating with your doctor. The doctor will always monitor your recovery, and would like you to avoid things that could hinder it. Therefore, you need to call your doctor before doing the following:

  • Before taking any medication, vitamin or supplement
  • Before participating in any physical sport, including contact and recreational sports
  • Before driving, riding a bicycle, playing sports or operating heavy machinery as your reaction times may have slowed due to brain injury

Here are some important tips to enhance recovery:

  • Repeatedly try to resume normal activities, especially if you feel stronger.
  • Always try to have good night sleep, and have rest in the daytime if you feel tired.
  • Write down things if you have difficulty memorizing or recalling. 
  • Do not drink alcohol, which hinders recovery and may cause falls (and another injury) if you came under influence
  • Talk with your family before making important decisions
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