Sign in Subscribe
Education

Intracranial Hemorrhages (ICH)

mLpenguin

• 1 min read
Intracranial Hemorrhages (ICH)
Photo by mojtaba mosayebzadeh / Unsplash

Epidural Hematoma (EDH)

  • What It Is:
    • Bleeding between the skull and dura mater
  • Cause:
    • Rupture of the middle meningeal artery (often due to temporal bone fracture)
  • Clinical Presentation:
    • Brief loss of consciousness → lucid interval → rapid deterioration
    • Headache, vomiting, focal deficits, signs of increased ICP (e.g. blown pupil)
  • Imaging:
    • Biconvex (lens-shaped) hyperdensity on CT
    • Does not cross suture lines
  • Think of teen/young adult with head trauma and lucid interval
  • Emergency neurosurgery (hematoma evacuation)
  • Can cause transtentorial herniation → CN III palsy, coma

Subdural Hematoma (SDH)

  • What It Is:
    • Bleeding between the dura and arachnoid
  • Cause:
    • Tearing of bridging veins
    • Seen in:
      • Elderly (brain atrophy)
      • Alcoholics
      • Shaken babies
      • Minor trauma in vulnerable brains
  • Clinical Presentation:
    • Gradual worsening of headache, confusion, somnolence, focal neurologic deficits
    • Acute: hours to days
    • Chronic: days to weeks
  • Imaging:
    • Crescent-shaped hyperdensity on CT
    • Crosses suture lines, but not midline
  • Elderly fall with slowly worsening mental status → think subdural
  • No lucid interval; symptoms evolve over time

Subarachnoid Hemorrhage (SAH)

  • What It Is:
    • Bleeding into the subarachnoid space (between arachnoid and pia)
  • Causes:
    • Ruptured berry aneurysm (e.g., anterior communicating artery)
    • AV malformation
    • Trauma
  • Clinical Presentation:
    • "Worst headache of my life" (sudden thunderclap headache)
    • May have photophobia, nuchal rigidity, vomiting
    • LOC or seizures may occur
    • Meningeal signs (Kernig, Brudzinski)
  • Imaging:
    • CT head (non-contrast): initial test → blood in sulci and basal cisterns
    • If negative and suspicion remains: LP → xanthochromia (RBC breakdown)
  • Sudden severe headache + nuchal rigidity → do CT first, then LP if needed
  • Prevent rebleeding with surgical clipping or coiling
  • Prevent vasospasm with nimodipine
  • "Lucid interval" after trauma → Epidural
  • Gradual somnolence in elderly after fall → Subdural
  • Thunderclap headache → Subarachnoid

When to do a LP?

  • YES: Suspected SAH with negative CT
    • Look for xanthochromia - yellow or light amber discoloration of cerebrospinal fluid (CSF), indicating the presence of bilirubin, a breakdown product of hemoglobin
  • NO: Any sign of mass effect or increased ICP
    • Risk of herniation