Intracranial hemorrhage

Abstract

Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuro-monitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.

Figure 1.

Intraparenchymal hemorrhage on computerized tomography scan. The hyperdense (bright) area represents acute bleeding (arrow). This location is suggestive of chronic hypertension, not compatible with an aneurysm, and would be highly atypical in trauma.

Figure 2.

Subarachnoid hemorrhage on computerized tomography scan. Hyperdense (bright) signal, indicating blood, surrounds the brainstem and fills the subarachnoid space. This appearance is typical of a ruptured aneurysm.

Figure 3.

Subdural hemorrhage on computerized tomography scan. Hyperdense (bright) signal, indicating blood, is seen on the patient's left. There is a midline shift to the patient's right.