Intracranial Hematomas

The brain is a very complex organ. Normally, it works very well and we hardly notice that it’s there. When there’s a disruption in the brain, it is quick to exhibit signs that something is not right. Intracranial hematomas are just one of many injuries that can cause wide and profuse problems. If not treated promptly, some intracranial hematomas can prove fatal.

Brain anatomy

The brain is one of the most highly profused organs in the body. It is housed in and protected by the cranium or skull. There are also three layers of meningeal tissue surrounding the brain which also serve as protection.

The dura mater is the outermost lining and closely lines the skull. Next is the arachnoid mater. Lastly, the pia mater closely lines the brain itself. Between the arachnoid and pia mater, cerebrospinal fluid cushions and supports the brain.

Hematoma

Hematomas are pools of mostly clotted blood that can develop in an organ, tissue or body space. Another common name for these are bruises. Just like you can get bruises on your leg, you can get bruises on or around your brain. Hematomas on or around the brain can much bigger problems than those on the leg, however.

Intracranial hematomas are hematomas inside of the cranium. There are three types of intracranial hematomas:

• Epidural
• Subdural
• Intracerebral

Medical Terminology

These prefixes may help you understand where in the brain the hematoma is located.

Epi– upon; an epidural hematoma is one that is UPON the dura, or between the dura and the skull.

Sub– under or below; a subdural hematoma is one that occurs BELOW the dura, between the dura mater and arachnoid layer.

Intra– inside; intracerebral hematomas occur INSIDE the brain itself.

Brain hematoma vs hemorrhage

A hematoma typically describes a collection of blood which has more or less clotted off, while hemorrhage describes ongoing bleeding.

What causes Intracranial Hematomas?

Intracranial hematomas are blood pooling within the brain or between the brain and the skull. The cause of this blood pooling could be

• Ruptured blood vessels
• Trauma such as a fall or car accident
• Head trauma mixed with blood thinners or Aspirin
• Arteriovenous malformations

Regardless of the cause, intracranial hematomas can cause a barrage of symptoms and pateints need to be seen in the Emergency Room as soon as possible.

Symptoms of an Intracranial Hematoma

• Dizziness or lightheadedness
• Drowsiness or progressive loss of consciousness
• Severe Headache (pts may complain of “worst headache of my life”)
• Confusion
• Slurred speech
• Paralysis on one side of the body (sometimes the side opposite of the brain injury, known as contralateral hemiplagia)

Risk factors for intracranial hematomas

Risk factors can include but are not limited to

• high blood pressure
• advanced age
• anticoagulant therapy
• AV malformations
• contact sports (football, hockey)
• Brain tumors

Epidural hematoma

An epidural hematoma is one that occurs between the dura mater and the skull itself. The cause is usually a tear in an artery after a skull fracture. They occur commonly with sports activities such as biking or skateboarding or from car or motorcycle accidents. They are more common in males and are rarely seen in patients younger than 2 or older than 60.

Causes

Additional causes of epidural hematomas unrelated to trauma include

• infection/abscess
• AV malformations
• Hemorrhagic tumors
• Coagulopathy

Symptoms

While epidural hematomas can occur with any number of symptoms listed above, these patients may also present with

• One pupil larger in diameter than the other
• Period of unconsciousness followed by a lucid interval that may last several hours. This is followed by unconsciousness and decline in brain function.  

If left untreated, these symptoms may proceed to seizures, breathing trouble, coma and death (death may occur in up to 15% of patients).

Diagnosis

Computed tomography scan (CT scan) or magnetic resonance imaging (MRI) is used to diagnose an epidural hematoma. If the hematoma is non-traumatic in nature, angiography may also be used to assist in diagnosis.

Treatment

Small hematomas may not require treatment, as the body is capable of reabsorbing the blood over several months. Vigilant monitoring is required with these patients.

Craniotomy and hematoma evacuation- this is the preferred surgical method of treatment. It involves removing a portion of the skull and removing the blood clot as well as stopping any obvious signs of active bleeding. The piece of removed skull is then replaced and secured with tiny screws.

Another treatment option is surgically placing a small hole or multiple holes in the skull (commonly called burr holes) and allowing the blood to drain that way. Sometimes a drain is places to assist with this, which may be left in for several days.

Medications

Mannitol-reduces brain swelling and decreases blood viscosity, which results in vasoconstriction and decreased intracranial pressure

Hypertonic IV solution such as 3% NS- higher concentrations of sodium in these fluids allows for fluid to be drawn out of edematous cerebral tissues

Glycerol- glycerol attracts water, which can pull water from the cerebral tissue and decrease swelling

Doctors may also prescribe steroids to assist in helping inflammation and antiseizure medications to prevent the patient from having a seizure.

Subdural hematoma

A subdural hematoma is bleeding below the dura mater, in between the dura mater and arachnoid layers of the brain’s protective outer layers. The most common cause of subdural hematomas is head injury due to trauma such as falling.

Subdural hematomas have three subcategories. These are

• Acute– bleeding occurs right after injury and is profound enough that the body cannot reabsorb the blood fast enough
• Subacute-bleeding occurs more slowly and symptoms are not present until days or weeks after injury. These often occur with concussions.
• Chronic-bleeding occurs slowly and symptoms don’t present for months. This type of hematoma is common in the elderly. Because of the delayed onset of symptoms, patients may not even remember the head injury itself.

Causes

Other causes of subdural hematomas include

• Head injury in pt on blood thinners
• Trauma in the eldery (due to brain shrinkage and tiny vessels being stretched)
• Contact sports
• Alcoholism (due to the liver’s inability to produce sufficient amounts of clotting proteins)
• Shaken baby syndrome in infants

Symptoms

Symptoms of subdural hematomas can include those listed above, as well as clinical findings such as

• Headache that won’t go away or gets worse
• Enlarged head in infants
• Personality changes

If left untreated, symptoms can progress to seizures, coma, brain herniation and death.

Subdural hematomas occur in approximately 25% of patients with head injury.

Diagnosis

CT or MRI are typically used to diagnose subdural hematomas. Occasionally, angiography can detect and help diagnose these hematomas.

Treatment

The treatment for subdural hematomas varies depending on the degree of bleeding.

Small or slow bleeding hematomas may require nothing more than monitoring. Bed rest or medications may be used to slow or stop small and chronic hematomas.

An acute subdural hematoma requires decompression surgery. This includes drilling burr holes in the patient’s skull to help drain blood. Additional surgery may be necessary to evacuate large clots and stop bleeding. Craniotomies (temporary removal of a portion of the skull) may also be indicated.

Medications

Mannitol-reduces brain swelling and decreases blood viscosity, which results in vasoconstriction and decreased intracranial pressure

Hypertonic IV solution such as 3% NS- higher concentrations of sodium in these fluids allows for fluid to be drawn out of edematous cerebral tissues

Glycerol- glycerol attracts water, which can pull water from the cerebral tissue and decrease swelling

Doctors may also prescribe steroids to assist in helping inflammation and antiseizure medications to prevent the patient from having a seizure.

Additionally in chronic subdural hematomas, providers may provide dexamethasone to reduce recurrence and low dose Atorvastatin to reduce hematoma volume.

Intracerebral Hematomas

Intracerebral hematomas are bleeding that occurs within the brain itself. These can occur close to the surface or deep within brain tissue. These types of hematomas require immediate treatment.  

Intracerebral hematomas are most often caused by severe head injury. Bleeding disorders, blood thinners or hypertension may complicate this type of injury.

Emergent surgery is needed to evacuate the clot and control bleeding in these situations, but depending on the location of the hematoma, surgery can be invasive and risky.

Cerebral edema(swelling) is common with these types of injuries and can quickly lead to brain herniation (brain matter being forced through small natural openings in the skull, such as the foramen magnum at the base of the skull). Brain herniation can have a mortality rate as high as 84%, so emergency treatment is an absolute necessity.

Unfortunately, brain injuries resulting from intracranial hematomas cause brain tissue loss. Full function may never be restored to these patients and permanent brain damage is highly likely.

Patient Education for Intracranial Hematomas

The biggest educational point for intracranial hematomas is prevention. Older adults need to be continuously educated about the risks of falling and ways to prevent falls, such as walking aids like canes or walkers.

Older people on blood thinners need continued education on the need to immediately report falls, even those where no injury is suspected. Even minor head injuries are enough to cause bleeding within the skull.

Patient on anticoagulant therapies, as well as those with high blood pressure need to report chronic or worsening headaches to their primary care provider as soon as possible.

Symptoms such as changes in mental status, sudden onset difficulty moving or speaking, complaints of “worst headache of my life” or loss of consciousness require immediate medical attention.

Nursing Education for Intracranial Hematomas

Patients involved in trauma of any kind, even a fall from standing, should be evaluated for bleeding within the brain. Young children with bicycle accidents and elderly patients on anticoagulation who experience only a minor head injury are among those in which a brain hemorrhage or hematoma are most often missed. It doesn’t have to be a serious injury to cause a bleed.

Medical treatment for hematomas should be quick and efficient. Familiarize yourself with the obvious signs of all categories of hematoma. Learn how to preform a quick exam while looking for any neurological symptoms.

Also learn about the medications used in the ER for brain hematomas. If your hospital does not have the capabilities to treat these patients, you’ll need to learn efficient transfer practices, as time is of the essence with these patients.