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Monday, 2 December 2013

Upper head hemorrhaging: Intracranial hemorrhage - The Types and Causes

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Intracranial hemorrhage
 Intracranial hemorrhage is defined as condition of bleeding within the skull.
D.1.1. Types of Intracranial hemorrhage
In the study to evaluate the sensitivity and specificity of head ultrasound (HUS) in the detection of intracranial hemorrhage in premature neonates compared with brain MRI using susceptibility-weighted imaging (SWI), showed that Ultrasound (US) and MRI scans of the brain using SWI in premature neonates were retrospectively evaluated for grade I-III germinal matrix hemorrhage (GMH), periventricular hemorrhagic infarction (PVHI), intra-axial hemorrhage other than PVHI, extra-axial hemorrhage in each cerebral hemisphere and cerebellar hemorrhage in each cerebellar hemisphere(1).
1. Intra-axial hemorrhage (cerebral hemorrhage)
Intra-axial hemorrhage is defined as a condition of  bleeding in the brain itself, including bleeding of the brain tissues and ventricles,

2. Extra-axial hemorrhage
Extra-axial hemorrhage is defined as a condition of skull bleeding outside of the brain

D.1.2. Causes and Rick factors
1. Causes 
a. Malignant melanoma
There is a report of a41-year-old female presented with repeated pontine hemorrhage. Histological examination showed malignant melanoma cells. No cutaneous lesion was found and positron emission tomography found no abnormalities. Our presumptive diagnosis was primary intra-axial brainstem malignant melanoma. The possibility of malignant melanoma should be considered in patients with intra-axial brainstem lesion associated with repeated hemorrhages(2).

b.  Head trauma
Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. In a study of a total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel(3).

c. High blood pressure
 In a cohort of patients with spontaneous ICH, we obtained ICP values from nursing documentation of hourly vital signs and reviewed charts to rule out spurious ICP recordings, showed that among 243 patients, 57 (24 %) underwent ICP monitoring, of whom 40 (70 %; 95 % CI 57-82 %) had an episode of ICP > 20 mmHg. Intracranial hypertension was less likely in older patients (OR per decade 0.6, 95 % CI 0.3-0.9) and after infratentorial hemorrhage (OR 0.1, 95 % CI 0-0.7). Intracranial hypertension was not independently associated with mRS scores (OR 0.8, 95 % CI 0.3-2.3); this remained true for a threshold of >25 mmHg (OR 0.5, 95 % CI 0.2-1.5), number of elevations (OR 0.98 per elevation, 95 % CI 0.96-1.00), or area under the curve (OR 1.00 per mmHg × h, 95 % CI 0.99-1.01)(4).

d. Cerebral Aneurysms
  Cerebral aneurysm is defined as a cerebrovascular disorder causes of the blood vessel to bulge or balloon out of the wall of a blood vessel as a result of the weaken of blood vessels and veins and occurred mostly at the bifurcations and branches of the large arteries located at the Circle of Willis. It can burst and cause bleeding into the brain(5) leading to Intracranial hemorrhage(5). 

e. Brain Arteriovenous malformations
 Brain Arteriovenous malformations is defined as a condition of abnormal connection between veins and arteries, with a high rate of bleeding into the brain usually congenital.

f. Cerebral Amyloid angiopathy
Cerebral Amyloid angiopathy is defined as a condition of  amyloid build up on the walls of  the blood vessel walls in the brain. Cerebral amyloid angiopathy (CAA) is one of the main causes of intracerebral hemorrhage (ICH), a subtypes of  Intracranial hemorrhage in the elderly, according to the study by the Institut de Recerca, Universitat Autònoma de Barcelona(6).

g. Blood or bleeding disorders.
In the study to analyze the association of the initial platelet count with mortality and progression of intracranial hemorrhage (ICH) in blunt traumatic brain injured (TBI) patients, showed that Of 626 TBI patients, 310 (49.5%) had a minimum of two brain computed tomography scans and were able to have ICH progression evaluated. Patients with platelets <175,000/mm3 had a significantly increased risk for ICH progression (OR [95% CI]: 2.09 [1.07-4.37]; adjusted p = 0.043). ICH progression was associated with increased need for craniotomy (OR [95% CI]: 3.27 [1.28-8.33]; adjusted p = 0.013) and mortality (OR [95% CI]: 3.41 [1.11-10.53]; adjusted p = 0.033). A platelet count <100,000/m3 was an independent predictor for mortality (OR [95% CI]: 9.5 [1.3-71.4]; adjusted p = 0.029)(7).

h. Neurosarcoidosis
Neurosarcoidosis, a complication of sarcoidosis in which inflammation occurs in the nervous system are related intracranial haemorrhage, according to the study by the incorporating the National Children's Hospital, Trinity College(8).

g. Liver disease 
Intracranial hemorrhages and late hemorrhagic disease associated cholestatic liver disease, according to the study of 11 infants with cholestatic liver disease with different etiologies exhibiting intracranial hemorrhage (ICH) to researchers at the  Erciyes University, Erciyesevler Mahallesi(9).

h. Brain tumors
There is a report of  three cases of metastatic brain tumors which began with the symptoms of vascular accident and were demonstrated as high density area by CT scan. Two of them are metastasis of lung cancer and another, hepatoma. Characteristic CT findings are as follow: 1) atypical location 2) non-homogeneous high density area extending from the margin of the tumor (sometimes ring-like appearance) 3) surrounding massive edema 4) positive contrast enhancement 5) multiple lesions(10).

i. Stroke and oral anticoagulants
Use of intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic stroke is restricted to patients with an international normalized ratio (INR) less than 1.7. However, a recent study showed increased risk of symptomatic intracranial hemorrhage after IV tPA use in patients with oral anticoagulants (OAC) even with an INR less than 1.7(11).

j. Etc.
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