Intracranial Hemorrhage: Types and Epidural Hematoma

00:00 So first let's talk about the evaluation of the intracranial hemorrhage. Step 1. What type of hemorrhage is it? How do you determine the type of hemorrhage? Well, here we use CT or computed tomography of the head without contrast. It's the most common test that we use. It's easy, efficient, and quick and can be proof of one that any emergency department or typically urgent cares as well to evaluate the cause of that hemorrhage. When we think about types of intracranial hemorrhage, there are 5 categories: Epidural hematomas, subdural hematomas, subarachnoid hemorrhage, intraparenchymal hemorrhage, and intraventricular hemorrhage. And we're using the findings of where the blood, where the hyperdensity appears on CT to determine the most likely cause of the hemorrhage.

00:48 Here, we see a schematic representation of those different types of hemorrhages. Epidural hemorrhages appear outside of the brain as lens-shaped lesions in between the 2 reflections of the dura. Just deep to the epidural hemorrhages and epidural space are subdural hemorrhages. Along the surface of the brain in the subdural space. These are crescent-shaped lesions occurring on the outer surface outside of the brain. Still deep to the subdural space is the subarachnoid space and hemorrhages occurring in that area are the subarachnoid hemorrhages. These are right directly on the surface of the brain in that subarachnoid space just outside of the pia mater of the brain and meningeal tissue and often present with symptoms of increased intracranial pressure. Next, moving deeper we get into the brain proper, the parenchyma of the brain. We can see 2 types of hemorrhages; lobar intraparenchymal hemorrhages and deep intracerebral Hemiplegia as we saw in the patient in our case. And then the final area of hemorrhage is intraventricular hemorrhage which is hemorrhage inside the ventricles. So let's walk intraventricular hemorrhage which is hemorrhage inside the ventricles. So let's walk through each of those types of hemorrhage and talk about the typical presentation and the diagnostic work-up and management for those patients. First, let's talk about epidural hematomas or epidural hemorrhage. An epidural hematoma occurs when blood accumulates between the skull and the dura mater, that thick membrane that covers the brain and you can see that here in the schematic. The classic symptoms of an epidural hematoma are a brief period of loss of consciousness followed by a period of awareness and then coma. We call that the lucid interval, that period where the patient is aware after their brief event of lucid interval which is common in patients presenting with an epidural hematoma. That lucid interval could last hours or minutes in length followed by deterioration of brain function. That lucid interval occurs as blood accumulates within the epidural space and eventually we see mass effect on the brain and even herniation that can contribute to the altered awareness and confusion or deterioration that occurs in these patients even progressing to coma. Epidural hematomas are an emergency if untreated. This condition can cause increased pressure on the brain, difficulty with breathing, damage and persistent long-term irreversible damage to brain function, and death. And we could also see other symptoms in addition to focal neurologic deficits but headache, vomiting, seizure from irritability of the cortical surface as well.

03:33 We evaluate these patients with a non-contrast head CT and we see what you see here a lens-shaped mass pushing the brain away from the skull and this appears as a hyperdensity or hemorrhage within the epidural space. And we can think about management in 2 categories. There is conservative management and surgery.

03:55 We consider conservative management for small epidural hematomas that remain stable and don't propagate or expand. We consider those for hematomas that do not result in pressure on the brain, local mass effect, or midline shift or herniation.

04:10 Conservative therapy can be considered. These patients are treated without surgery but monitored closely during that initial window to ensure that the patient will not clinically deteriorate or the hematoma or hemorrhage will not expand. But surgery is really common for these patients and we consider that for patients with severe headache and focal neurologic deficits or deterioration in brain function or clinical exam. Surgery is indicated for epidural hematomas larger than 1 cm and measured at the thickest point from the inside of the skull to the outside or inside of the hemorrhage, the far aspect of hemorrhage and these are really indications for surgery which is performed through craniotomy, removal of the skull, evacuation of the hemorrhage, and then replacement of the skull which is very successful in these patients when initiated early. An early surgery is critical for managing an epidural hematoma.