Intracranial hematomas
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Intracranial hematomas, also intracranial hemorrhage, are bad stuff that keep neurosurgeons busy. They are usually diagnosed by imaging (CT head).
Not much bleeding is needed to cause death. In a person without atrophy (to provide space for the blood) ~75 ml is considered enough if it is acute.[1]
Clinical
- Headache.
- Neck stiffness.
- Vomit without diarrhea.
- Changes in level of consciousness.
Classification
By location
- Epidural hemorrhage (extradural hemorrhage).
- Patient may have lucid interval.[2]
- Middle meningeal artery.
- Radiology: biconvex.
- Subdural hemorrhage
- Damaged bridging veins: subdural space between the dura and arachnoid mater.[3]
- Radiology: crescent shape.
- Subarachnoid hemorrhage.
- Classically caused by aneuryms:[4]
- Anterior communicating artery (ACA) - most common.
- Middle cerebral artery (MCA) - second most common.
- Classically caused by aneuryms:[4]
- Intracerebral hemorrhage.
- > 60 ml at presentation (assessed via CT scan) assoc. with > 90% 30 day mortality.[5]
By vessel type
- Arterial - common.
- Venous - rare (~3-4 cases/1,000,000 people/year[6]).
Cerebral venous thrombosis
- See also: Thrombosis.
General
- Extremely rare.
- Female > male.
- May be associated with trauma.[7]
- Presentation often mimics subarachnoid haemorrhage.[8]
- Typically involves superior sagittal sinus.[8]
Gross
- Bilateral involvement.
- Congested appearance.
Epidural hematoma
- AKA epidural hemorrhage
General
- Extradural hemorrhage.
- Patient may have lucid interval.[2]
- Classically due to an injury of the middle meningeal artery.
- Usually due to trauma.
- Generally considered artefactual in the context of fire deaths.[11]
Gross
- Blood outside of the dura.
Radiology:
- Biconvex.
Microscopic
Features:
- +/-Extravasated red blood cells.
- +/-Hemosiderin-laden macrophages.
Subdural hematoma
- AKA subdural hemorrhage.
- Abbreviated SDH.
General
Where/what:
- Bridging veins in subdural space between the dura and arachnoid mater - injured.[3]
Why?
- +/-Trauma.
- Elderly, esp. those with cerebral atrophy.[12]
Recurrance risks:
Gross
- Blood in the subdural potential space.
- Crescentic shape.
Microscopic
Features:
- Blood in subdural (potential) space.
Images
SDH - very low mag. (WC)
SDH - intermed. mag. (WC)
Subarachnoid hematoma
- Abbreviated SAH.
- AKA subarachnoid hemorrhage.
General
- In the forensic context SAH alone is not good enough.
- One needs to determine the cause, e.g. ruptured berry aneurysm or laceration of left vertebral artery.
DDx:
- Trauma - most common, see section below.
- Ruptured berry aneurysm ~80% of non-traumatic SAH.[14]
- Arteriovenous malformation and other vascular anomalies.
Traumatic SAH
- May have a characteristic mastoid contusion.
- May be associated with vascular Ehlers-Danlos syndrome.
Gross
- Blood between pia mater and arachnoid membrane.
- Typically at the base of the brain.
Note:
- Ruptured berry aneurysms are best found when the brain is fresh; it is hard to dissect away fixed blood.
Intracerebral hematoma
- AKA intraparenchymal hemorrhage, AKA intracerebral hemorrhage.
General
Causes:[15]
- Hypertension - usually putamen, thalamus, pons, cerebellum - see intracerebral hematoma in hypertension.
- Cerebral amyloid angiopathy - usually superficial (cortex & subcortical white matter) & frontal lobe or parietal lobe.[16]
- Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).[17]
Gross
- Blood within the parenchyma of the brain.
Microscopic
- +/-Hemosiderin-laden macrophages.
Cerebral fat embolism
General
- Etiology: trauma.
- May be associated with pulmonary fat embolism.
Gross
Features:[18]
- Multiple white matter predominant petechiae.
DDx - medical imaging:
- Diffuse axonal injury[19] - severe DAI classically has a corpus callosum injury.
- Herpes simplex encephalitis - temporal lobe hemorrhage.
Images:
Microscopic
Features:[18]
- Intravascular fat globules.
See also
- Cerebral amyloid angiopathy.
- Duret hematoma.
- Forensic pathology.
- Hypertension.
- Neuropathology.
- Scalp hematomas.
References
- ↑ McAuliffe. 15 October 2010.
- ↑ 2.0 2.1 Erşahin Y, Mutluer S, Güzelbag E (April 1993). "Extradural hematoma: analysis of 146 cases". Childs Nerv Syst 9 (2): 96–9. PMID 8319240.
- ↑ 3.0 3.1 Crooks DA (1991). "Pathogenesis and biomechanics of traumatic intracranial haemorrhages". Virchows Arch A Pathol Anat Histopathol 418 (6): 479–83. PMID 2058082.
- ↑ Beck J, Rohde S, Berkefeld J, Seifert V, Raabe A (January 2006). "Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography". Surg Neurol 65 (1): 18–25; discussion 25–7. doi:10.1016/j.surneu.2005.05.019. PMID 16378842.
- ↑ URL: http://stroke.ahajournals.org/cgi/content/abstract/24/7/987. Accessed on: 2 September 2010.
- ↑ Agostoni E, Aliprandi A, Longoni M (April 2009). "Cerebral venous thrombosis". Expert Rev Neurother 9 (4): 553–64. doi:10.1586/ern.09.3. PMID 19344306.
- ↑ URL: http://emedicine.medscape.com/article/1162804-overview. Accessed on: 12 October 2010.
- ↑ 8.0 8.1 URL: http://www.jpma.org.pk/full_article_text.php?article_id=932. Accessed on: 12 October 2010.
- ↑ Milandre L, Pellissier JF, Vincentelli F, Khalil R (1990). "Deep cerebral venous system thrombosis in adults". Eur. Neurol. 30 (2): 93–7. PMID 2187698.
- ↑ MSP. 12 October 2010.
- ↑ Ritter, C. (1990). "[A heat gelatinized subdural hematoma in a burned cadaver as an indication of a vital accident].". Z Rechtsmed 103 (3): 227-30. PMID 2309533.
- ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 663. ISBN 978-1416054542.
- ↑ Chon, KH.; Lee, JM.; Koh, EJ.; Choi, HY. (Sep 2012). "Independent predictors for recurrence of chronic subdural hematoma.". Acta Neurochir (Wien) 154 (9): 1541-8. doi:10.1007/s00701-012-1399-9. PMID 22653496.
- ↑ Ingelmo Ingelmo, I.; Fàbregas Julià, N.; Rama-Maceiras, P.; Hernández-Palazón, J.; Rubio Romero, R.; Carmona Aurioles, J. (Dec 2010). "[Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach].". Rev Esp Anestesiol Reanim 57 Suppl 2: S4-15. PMID 21298906.
- ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 665. ISBN 978-1416054542.
- ↑ Haacke, EM.; DelProposto, ZS.; Chaturvedi, S.; Sehgal, V.; Tenzer, M.; Neelavalli, J.; Kido, D. (Feb 2007). "Imaging cerebral amyloid angiopathy with susceptibility-weighted imaging.". AJNR Am J Neuroradiol 28 (2): 316-7. PMID 17297004.
- ↑ Choi, JC.; Kang, SY.; Kang, JH.; Park, JK. (Dec 2006). "Intracerebral hemorrhages in CADASIL.". Neurology 67 (11): 2042-4. doi:10.1212/01.wnl.0000246601.70918.06. PMID 17135568.
- ↑ 18.0 18.1 Kamenar, E.; Burger, PC.. "Cerebral fat embolism: a neuropathological study of a microembolic state.". Stroke 11 (5): 477-84. PMID 7423578.
- ↑ Kumar, S.; Gupta, V.; Aggarwal, S.; Singh, P.; Khandelwal, N.. "Fat embolism syndrome mimicker of diffuse axonal injury on magnetic resonance imaging.". Neurol India 60 (1): 100-2. doi:10.4103/0028-3886.93597. PMID 22406792.
- ↑ URL: http://www.duke.edu/~ema5/Golian/Slides/3/fluids-hemo.htm. Accessed on: 25 March 2012.
- ↑ Eriksson, EA.; Schultz, SE.; Cohle, SD.; Post, KW. (Apr 2011). "Cerebral fat embolism without intracardiac shunt: A novel presentation.". J Emerg Trauma Shock 4 (2): 309-12. doi:10.4103/0974-2700.82233. PMC 3132375. PMID 21769222. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132375/.