Differential diagnosis of intracranial hemorrhage
1. EDH( Epidural hematoma)
- biconvex or lentiform appearance
- between skull and dura
- less frequently seen than SDHs
- result of bleeding from middle meningeal artery or dural venous sinus
-通常發生在受撞擊的同側，頭骨外邊常見腫脹的頭皮
- most common site: temporoparietal region( where the anterior or posterior division of the middle meningeal artery)
-20~30%出現 lucid interval : At initial time of injury, can be asymptomatic except for pain at the external part of insult
- Patients will frequently complain of mental status changes, severe headache, nausea, and vomiting.
- Death often ensues from increasing pressure and compression caused by the enlarging hematoma, uncal (i.e., transtentorial), gyral, and cerebellar tonsillar herniation and subsequent compression of the brain stem.
2. SDH ( Subdural hematoma)
- crescent shaped
- between brain and dura
- more common than epidural hematomas
- bleeding from bridging cortical veins (bleeding slowly, development of clinical signs and symptoms can be delayed.)
- It can range from asymptomatic to altered levels of consciousness or paralysis.
- SDHs are more common in patients with brain atrophy such as alcoholics or the elderly: because the superficial veins of those with brain atrophy are stretched over greater distances and are therefore more prone to rupture with rapid head movement.
-classification: (依事故發生後出現時間)
Acute: 3 days
Subacute: 3 days~3 weeks
Chronic: more than 3 weeks(prognosis最佳，好發elderly(75%), alcoholics, and child)
3. SAH (Subarachnoid hemorrhage)
- within cisterns and sulci, Defined as blood within the CSF subarachnoid space
- atypical headaches which are abrupt in onset and severe (patient experiences worst headache ever), neck stiffness
-Spontaneous subarachnoid hemorrhages: rupture of arterial aneurysms(以DSA確診), 好發於 circle of Willis
- rapidly increases intra cranial pressure
- Hunt & Hess Grading(與prognosis有絕對相關)
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Hunt & Hess Grading |
Description |
|
Grade 1 - Asymptomatic or mild headache |
病人清醒，輕微頭痛 |
|
Grade 2 - Moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than possible cranial nerve palsy |
病人清醒，嚴重頭痛和頸部僵硬 |
|
Grade 3 - Mild alteration in mental status (confusion, lethargy), mild focal neurological deficit |
開始有輕微神智問題，如想睡、手腳無力 |
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Grade 4 - Stupor and/or hemiparesis |
嚴重神智問題，如conscious change，或手腳偏癱 |
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Grade 5 - Comatose and/or decerebrate rigidity |
瀕臨死亡 |
- Fisher’s grading：以CT scan看出血量，與prognosis有絕對相關。
|
Grading |
Description |
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Group 1 - No blood detected |
CT看不到血（lumbar puncture知有出血） |
|
Group 2 - Diffuse deposition of subarachnoid blood, no clots, and no layers of blood greater than 1 mm |
可見少量的血(< 1mm) |
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Group 3 - Localized clots and/or vertical layers of blood 1 mm or greater in thickness |
血較多，且形成血塊(> 1mm) |
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Group 4 - Diffuse or no subarachnoid blood, but intracerebral or intraventricular clots are present |
在腦室或腦實質內，有血或血塊 |
- Diagnosis of SAH：
(1). CT scan：發作後五天之內照的片子較為可信；五天之後，血液被分解。
(2). CSF study from lumbar puncture：臨床表現上高度懷疑是SAH，發作超過五天時再使用（為了避免造成herniation）。
-complication:
三大—re-bleeding，vasospasm, hydrocephalus
三小—Seizure, Electrolyte imbalance, Arrhythmia、Heart attack
4. ICH (Intracerebral Hemorrhage)
- Defined as hematomas deep within the brain tissue
-location: putamen (2/3), thalamus, caudate, cerebellum, and brainstem
- tends to reoccur after 6~12 hrs
-reason: hypertension, trauma, bleeding diatheses, amyloid angiopathy, illicit drug use, and vascular malformations.
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EDH |
SDH |
SAH |
ICH |
|
location |
between skull and dura |
between brain and dura |
CSF所在處 |
brain tissue |
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CT形狀 |
梭狀 |
新月型 |
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|
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流血位置 |
middle meningeal artery, temporoparietal region最多 |
bridging cortical veins |
cisterns and sulci |
putamen, thalamus, caudate, cerebellum, and brainstem |
|
症狀 |
mental status changes, severe headache, N/V |
from asymptomatic to conscious change or paralysis. |
Severe headache, neck stiffness |
看位置 |
|
特色 |
lucid interval, 受撞擊的同側 |
alcoholics or elderly 等brain atrophy 者為高危險群 |
1.Hunt & Hess Grading 2.Fisher’s grading |
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