Intra cranial hemorrrhage

1-Staging of intra cranial hematoma

-Acute hematoma---hyper dense.

-Sub acute hematoma---iso dense.

-Chronic hematoma---Hypo dense.

2-Sites of intra cranial hemorrhage:

-Epi dural or extra dural hematoma---between the dura and the skull bone.

-Sub dural hematoma---between  the dura and the arachnoid.

-Sub arachnoid hematoma---below the sub arachnoid, here you observed that this kind of hemorrhage is entering inside cortical sulci.

-Intra parenchymal hematoma---hemorrhage inside the brain parenchyma.

-Intra ventricular hematoma---hemorrhage inside the ventricle.

3-Anatomic Localization:

-Extra axial hematoma = hematoma outside the brain tissue as epi dural, sub dural and sub arachnoid hematomas.

-Intra axial hematoma = hematoma inside the brain parenchyma as intra parenchymal hematoma.

-Intra ventricular hematoma could be considered as extra axial or intra axial.

4-Sub arachnoid hemorrhage:

-Means blood in the CSF.

-Seen in sulci and cisterns.

-Most common cause is rupture of an aneurysm.

5-Epi dural hematoma:

-If the hematoma is adherent to the bone and moving along with the bone, this will be extra axial hematoma.

-If there is a brain tissue between in the bone and the hematoma, so it will be intra axial hematoma.

-The epi dural hematoma shows convex inner margin which can cross the mid line and it is almost always in the acute stage as patient should be manifested early.

-In case of epi dural hematoma, the dura is strictly adherent to the skull bones, so the epi dural hematoma will face a very strong resistence to migrate anterior or posterior, so it is more easy to press upon more liable brain tissue making this convex inner border, so the hematoma will increase in size transversely and not longitudinally.

6-Sub dural hematoma:

-Sub dural space is not limited anteriorly and posteriorly, so sub dural hematoma can move freely above and down making concave inner border which do not cross the mid line and it can be acute, sub acute or chronic in staging.

-Can be seen in the inter hemispheric fissure.

-Usually seen in the elderly with history of minor trauma.

7-Intra parenchymal hematoma:

-It could be primary or secondary to trauma.

-If it is secondary to trauma, this is known as contusion.

-So if this hematoma is associated with history of fracture and evident fracture seen on radiology, this is a brain contusion and not intra parenchymal hematoma.

-If there is no history of trauma or fracture, this will be the hematoma caused by cerebro-vascular stroke seen routinely in the practice.

-Intra parenchymal hematoma caused by cerebro-vascular insult is usually been situated near the ventricle, and as the wall of the ventricle is too smooth, so it will be easy for the hematoma to penetrate it and reach the ventricle to form intra ventricular hemorrhage.

-So we have two causes producing intra ventricular hematoma which are intra parenchymal hematoma and sub arachnoid hematoma.

8-Follow up of intra cranial hematoma:

-Epi dural hematoma is almost always acute due to severe symptoms as it occurs in a tight space. Patient are usually evaluated by CT and evacuation is done on emergency basis.

-Sub dural hematoma can be acute, sub acute and chronic due to minor symptoms as it occurs in a wide space, patients are usually evaluated by CT and evacuation is done usually in the chronic stage.

-If we see a sub dural hematoma with fluid level with hypo and hyper dense density along the side of this level, this appearance is considered sub acute hematoma.

-So we have three pictures for sub acute hematoma

*The first is when it is iso dense to the density of the brain, here we can know its presence by its effect on the sulci and also by mass effect if present.

*Secondly by presence of sedimentation level.

*Thirdly by presence of white and black densities along the hematoma.

9-Causes of iso dense lesions causing mass effect are two

-Sub acute sub dural hematoma leading to intact grey white matter interface.

-Infiltrating glioma leading to disappearance of grey white matter interface due to its destruction by the tumor.
-This is better evaluated by MRI.