Traumatic versus Non-Traumatic Intracerebral (Intracranial) Bleeds

1. Traumatic versus Non-Traumatic
Intracerebral (Intracranial) Bleeds
Dr Amit Agrawal, MCh
Department of Neurosurgery
Narayana Medical College and Hospital
Chintareddypalem, Nellore (AP), India

2.  Conflict of interest: None

3.  45 year male
 Uncontrolled hypertension
 Fall from bed
 GCS-E1V1M1
 Pupils B/L fixed
Case 1

4.  45 year male
 Road traffic accident
 Chronic alcoholic
 GCS-E1V1M1
 Pupils B/L fixed
Case 2

5.  35 year male
 Uncontrolled hypertension
 Had fall
 One episode of seizures
 GCS-E2V3M5
 Pupils B/L reacting
Case 3

6.  50 year male
 Uncontrolled hypertension
 Had fall in bathroom
 GCS-E3V3M5
 Pupils B/L reacting
Case 4

7.  55 year male
 Road traffic accident
 No hypertension
 GCS-E3V4M5
 Pupils B/L reacting
Case 5

8. The puzzle of TICH/SICH

9. Intracranial
hemorrhage
TICH
TICH in a
patient with
risk factors
SICH
Patient with
risk factors
had
concomitant
trauma

10. Why it is important to know is it TICH
or SICH??
 It has a clinical significance
 Management and outcome differs
 It has a medico-legal significance

11.  Epidural hematoma
 Subdural hematoma (acute versus chronic)
 Subarachnoid hemorrhage (SAH)
 Hemorrhagic parenchymal contusions
 Cerebral microhemorrhage (Diffuse axonal injury)
 Intra-ventricular hemorrhage
 Intraparenchymal hemorrhage
 Supratentorial
 Lobar
 Putamenal
 Thalamic
 Caudate
 Infratentorial
 Cerebellar
 Brain stem
Types of Intracranial Hematomas

12. Risk Factors for ICH
 Trauma
 Arteriovenous
malformation
 Rupture of berry aneurysm
 Secondary to infection
 Brain tumor
 Vasculitis
 Hemorrhagic
transformation of prior
cerebral infarction
 Coagulopathies
 Vasculitis
 Hemorrhagic
transformation of prior
cerebral infarction
 Coagulopathies
Caplan LR Intracerebral hematomas. In: H Kaufmann, ed. New York: Raven Press, 1992; 34
Wiener H, et al. The management of spontaneous intracerebral haemorrhage. Contemp Neurosurg
1992; 14: 1-8

13.  Definite history of trauma
 May not be history of trauma (trauma may be minor)
 Previous history of bleeding disorders
 Taking anticoagulant medications
 Minimum signs of injuries i.e. scalp or other parts of the
body
 EDH without skull fracture
 Presence of aneurysm on angiography
Approach: Clinical First

14. Investigations
 Complete blood count
 Prothrombin time
 Activated partial
thromboplastin time
 Electrolytes
 Electrocardiography
 Chest x-ray
 Computed tomography
(CT)
 Initial primary key
investigation
 MRI with MRA
 Cerebral angiography

15. CT MRI/M
RA
Size and location √ √
Hydrocephalus √ √
Hemorrhagic vs. ischemic stroke √ √
Ventricular extension √ √
Structural abnormalities i.e. aneurysms,
AVM, brain tumors
√ √√
Imaging (SICH/TICH)

16. Contrast CT Angiography
Young patient (< 40 years) √ √
Who do not have a specific cause for
hemorrhage
√ √
Atypical appearance/location of the
clot
√ √
Suspicion of an aneurysmal bleed
(Sylvian or interhemispheric fissures)
√ √
Patients with IVH plus ICH √ √
Additional investigations
Bakar IA, et al. Diagnostic Cerebral Angiography in Spontaneous Intracranial Haemorrhage: A Guide for
Developing Countries. Asian J Surg 2005;28(1):1–6.
Hino A, et al. Value of Repeat Angiography in Patients With Spontaneous Subcortical Hemorrhage.
Stroke. 1998;29:2517-2521.
Zhu XL, et al. Spontaneous Intracranial Hemorrhage: Which Patients Need Diagnostic Cerebral
Angiography? A Prospective Study of 206 Cases and Review of the Literature Stroke. 1997;28:1406-
1409.

17. SICH TICH
Airway, breathing, and circulation √ √
Detection of focal neurological
deficits
√ √
Detecting any signs of external
trauma
√ √
Stability of vital functions prior to
scanning
√ √
Emergency room management

18. SICH TICH
Fluid resuscitation (Euvolemia) √ √
Electrolytes √ √
Acidosis and alkalosis √ √
Control of body temperature √ √
Prevention of Seizures √ √
Correct coagulation abnormalities √ √
Emergency management contd.
• Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA: The
role of secondary brain injury in determining outcome from severe head injury. J Trauma 34: 216–222, 1993
• The Japanese Association for The Surgery of Trauma: [Japan Advanced Trauma Evaluation and Care, ed 2]. Tokyo,
Herusu Shuppan, 2004, pp 1–21 (Jpn)
• Kokoska ER, Smith GS, Pittman T, Weber TR: Early hypotension worsens neurological outcome in pediatric patients
with moderately severe head trauma. J Pediatr Surg 33: 333–338, 1998
• Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J: The deleterious effects of intraoperative
hypotension on outcome in patients with severe head injuries. J Trauma 33: 403–407, 1992

19.  Prioritize the management of systemic factors
(injuries)
 Balance the necessity of controlling abdominal or
thoracic hemorrhage against the potential risk of
delaying craniotomy
 Blood pressure reduction
 Optimal level based on individual factors
 Management of ICP
 Optimal head position
 Osmotherapy (Mannitol vs 3% saline)
Medical Management (SICH/TICH)
The Japan Society of Neurotraumatology: [JSNT Guideline, ed 2]. Tokyo, Igaku Shoin, 2007, pp 1–21 (Jpn)
Thomason M, et al. Head CT scanning versus urgent exploration in the hypotensive blunt trauma
patient. J Trauma 1993;34: 40–45.
Fukai J, et al. Timing of Craniotomy in a Patient With Multiple Trauma Including Head Injury—Case
Report— Neurol Med Chir (Tokyo) 2009;49, 22-25.

20. SICH TICH
Safe and thorough clot evacuation √ √
Maximal preservation of neurological
function
√ √
Should minimize the secondary brain damage √ √
Should be performed before irreversible
brainstem damage or generalized brain
damage
√ √
Diagnosis and emergent treatment of severe
systemic injuries and ongoing hemorrhagic
shock
- √
Surgery-objectives
American College of Surgeons Committee on Trauma: Initial assessment and management, in:
Advanced Trauma Life Support for Doctors, Instructors Course Manual. Chicago, American College of
Surgeons, 1997, pp 21–46
The Japan Society of Neurotraumatology: [JSNT Guideline, ed 2]. Tokyo, Igaku Shoin, 2007, pp 1–21
(Jpn)

21. Surgery-Indications
SICH TICH
Haematoma volume 20—80 ml >25 ml
Lobar/superficial haematomas √ √
Younger patients with worse or
deteriorating GCS scores √ √
Midline shift/raised ICP √ √
The presence of lateralizing signs √ √
The wishes of the patient/family √ √
Barbara A. et al. International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage. Stroke.
2003;34:2593-2598.
Tsementzis SA. Surgical management of intracerebral hematomas. Neurosurgery. 1985;16:562–572.
Siddique MS, et al. Surgical treatment of intracerebral haemorrhage
Fernandes HM, et al. Spontaneous intracerebral haemorrhage: a surgical dilemma. Br Neurosurg 1999; 13: 389-94
Mathiesen T, et al. Traumatic intracerebral lesions without extracerebral haematoma in 218 patients. Acta Neurochir
(Wien). 1995;137(3-4):155-63.

22. SICH TICH
Conventional craniotomy √ √√
Ultrasound-guided endoscopic clot
removal
√ √
Stereotactic removal √ √
Stereotactic infusion of tissue plasminogen
activator (rtPA), Urokinase
√ √
Surgery-options
Auer LM, et al: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomised
study. J Neurosurg, 1989; 70: 530–35
Nakano T, et al: Neuroendoscopic surgery for intracerebral haemorrhage. Comparison with traditional therapies.
Minim Invas Neurosurg, 2003; 46: 278–83
Nasser JA et al. Stereotactic fibrinolysis of spontaneous intracerebral hematoma using infusion of recombinant tissue
plasminogen activator. Arq Neuropsiquiatr 2002;60(2-B):362-366.
Marquardt G, et al: Manual stereotactic aspiration of spontaneous deep-seated intracerebral haematomas in non-
comatose patients. Br J Neurosurg, 2001; 15: 126–31..

23. SICH TICH
The severity of bleeding √ √
The level of consciousness on admission √ √
Cortical location √ √
Age younger patients √ √
Intraventricular spread of the bleeding √ √
Hydrocephalus √ √
First-day MAP √ -
Low fibrinogen levels √ -
Prognosis
Broderick JP, et al. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg.
1993;78:188-191.
Fogelholm R, et al. Prognostic Value and Determinants of First-Day Mean Arterial Pressure in Spontaneous Supratentorial
Intracerebral Hemorrhage. Stroke. 1997;28:1396-1400.
Togha M, et al. Factors associated with in-hospital mortality following intracerebral hemorrhage: a three-year study in
Tehran, Iran. BMC Neurology 2004, 4:9 .

24. Prognosis
SICH TICH
Associated subdural haematomas - √
Temporal localization of hematoma - √
Multipl/bilateral contusions - √
Inadequate resuscitation for
extracranial bleeding
- √
Djurovic BM, et al. [Neurosurgical treatment of spontaneous and traumatic intracerebral hematomas] [Article in Serbian] Acta Chir
Iugosl. 2008;55(2):123-7.
Mushkudiani NA, et al. Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J
Neurotraum 2007;24(2):259–69.
MRC CRASH trial collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of
international patients. BMJ 2008;23,336(7641):425–9.

25.  There are similarities and differences between TICH and
SICH
 High index of clinical suspicion
 Careful consideration of the pattern of ICH, patient
symptoms and demographics, and associated vascular or
post-contrast imaging may reveal the diagnosis in most
situations
Conclusion