Intracranial Hemorrhage

Basics

Description

The pathologic accumulation of blood into the epidural, subdural, subarachnoid, intraparenchymal, or intraventricular space within the cranium due to loss of blood vessel integrity or coagulopathy

Epidemiology

  • Intraventricular hemorrhage is rare beyond the newborn period.
  • Trauma: common cause of ICH in children
  • Arteriovenous malformations (AVMs): most common cause of nontraumatic ICH in children

Incidence

Incidence of hemorrhagic (nontraumatic) stroke is 1.1 per 100,000 person years.

Risk Factors

Increased frequency with hereditary disorders of coagulation, congenital heart disease, and polycystic kidney disease associated with intracranial aneurysms

Genetics

Multiple cerebral cavernomas may be associated with autosomal dominant trait with CCM1, CCM2, and CCM3.

General Prevention

  • Automobile seat belts
  • Bicycle, skating, and skateboarding helmets
  • Child abuse prevention
  • Diving safety practices
  • Preventing falls
  • Maintaining safe driving speeds
  • Keeping children away from firearms
  • Hematologic monitoring for those at risk for hemorrhage due to bleeding disorders

Pathophysiology

  • Epidural hematoma (blood between the dura mater and the skull) is frequently arterial, related to skull fracture; typically middle meningeal artery bleeding following temporal bone fracture; may also arise from dural venous sinus laceration.
  • Subdural hematoma (blood between the dura mater and the arachnoid membrane) is frequently venous from trauma causing stretching and tearing of bridging cortical veins or coagulopathy.
  • Subarachnoid hemorrhage (blood between the arachnoid membrane and brain): ruptured intracranial aneurysm, AVM, or trauma
  • Intraparenchymal hemorrhage: trauma, infections (herpes simplex encephalitis, bacterial endocarditis), coagulopathy, brain tumor, Moyamoya arteriopathy, venous sinus thrombosis, or cerebral infarction (occurs mostly with rupture of medium or smaller branches of major cerebral arteries)
  • Intraventricular hemorrhage: may occur in isolation (more frequent in preterm infants <36 weeks gestation) or in a mixed pattern with intraparenchymal or subarachnoid hemorrhage. In term infants, rule out venous sinus thrombosis (especially in patients with accompanying thalamic hemorrhage).
  • 4 grades of intraventricular hemorrhage:
    • Grade I: isolated to 1 or both germinal matrices
    • Grade II: intraventricular hemorrhage without ventricular dilatation
    • Grade III: intraventricular hemorrhage with ventricular dilatation (hydrocephalus)
    • Grade IV: intraventricular hemorrhage with ventricular dilatation and extension into the periventricular white matter

Etiology

  • Vascular
    • Congenital vascular anomalies: aneurysm, AVM, cavernous hemangioma, arteriovenous fistula, vein of Galen malformation
    • Developmental/acquired vasculopathy: Ehlers-Danlos syndrome type IV, Moyamoya arteriopathy, sickle cell disease, hypertension (posterior reversible encephalopathy syndrome [PRES]), infective aneurysm, vasculitis (cocaine, inflammatory diseases), cerebral venous sinus thrombosis, hemorrhagic conversion of ischemic stroke, brain tumor
  • Hematologic abnormalities: thrombocytopenia, hemophilia, sickle cell disease, liver failure, disseminated intravascular coagulation, iatrogenic (ECMO or anticoagulation therapy)
  • Traumatic
    • Accidental injury
    • Nonaccidental injury
ALERT
ICH, especially in young infants and children without an obvious etiology, should raise the suspicion of nonaccidental trauma.

Commonly Associated Conditions

  • Prematurity
  • Hemophilia (prevalence of ICH 3–12%)
  • Sickle cell disease (250-fold increased risk of ICH)
  • Bacterial endocarditis
  • Venous infarction
  • Arterial infarction
  • Alcohol, cocaine, and other sympathomimetics

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