What is an Intracranial Hemorrhage?

Courtesy of Godoy Medical Forensics

 

Intracranial hemorrhage (ICH) is an accumulation of blood inside the skull in or around the brain that can have traumatic and non-traumatic causes. Bleeding may occur in the brain parenchyma (intercerebral) or in the surrounding coverings on the brain. The accumulation of blood inside the skull causes pressure on the brain and decreased circulating blood flow, which brings oxygen to the brain cells. The pressure and lack of oxygen causes the brain cells to die and causes damage to the nerves, which control other bodily functions.

Is Trauma the Only Cause of Intracranial Hemorrhage?

Intracranial hemorrhage may have traumatic and non-traumatic causes. One non-traumatic cause is hemorrhagic stroke, which accounts for 8 to 13 percent of all strokes. Hemorrhagic strokes often have a poor prognosis resulting in death or major disability. Hypertension is the most common cause of non-traumatic intercerebral hemorrhage because it causes damage to the blood vessels in the brain. Other non-traumatic causes include bleeding aneurysms, bleeding from anticoagulant medications, tumors and infections (Liebeskind, 2014). Risk factors for hemorrhagic stroke include advanced age, high blood pressure, previous stroke, alcohol abuse, and use of illicit drugs, such as cocaine. Risk of hemorrhagic stroke can be reduced by controlling modifiable risk factors, such as taking prescribed medications for blood pressure, limiting alcohol use, and avoiding the use of illicit drugs.

Patients taking “blood thinners,” such as Coumadin or Plavix are at increased risk of traumatic intracerebral bleeding from blunt head trauma. Intracranial hemorrhage can happen from blunt force trauma and can happen in various situations. Head trauma can happen as the result of motor vehicle accidents and accidental falls. Trauma causing intracranial bleeding may also happen by being struck by a firm object such as a fist, crowbar, or bat.

What are the Three Main Kinds of Brain Bleeding?

Epidural hemorrhage is bleeding between the skull and outer covering of the brain, the dura matter.  Epidural hemorrhages are frequently caused from a blunt trauma from an assault, fall, or other accident. Approximately 17 percent of patients with epidural hemorrhage will deteriorate to coma following trauma.

A subdural hematoma is a collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane. This is the most common type of traumatic brain bleeding.  Subdural hematoma may also be spontaneous or caused by a procedure such as a lumbar puncture. Death rates can be high, even with the best medical and neurosurgical care (Meagher, 2013). The prognosis depends on the amount of direct brain damage and the damage resulting from the mass effect of the hematoma on the brain (amount of pressure causing the brain to shift or “push” within the skull). The mortality rate for subdural hematoma is about 60 to 80 percent (Dawodu, 2013).

 

A subarachnoid hemorrhage (SAH) is bleeding between the pia and arachnoid membranes covering the brain. The most common cause is head trauma. However, some use the term SAH in the setting of non-traumatic hemorrhage, such as those caused by cerebral aneurysm. Intracranial saccular aneurysms represent the most common cause of nontraumatic SAH. About 80 percentof SAH result from ruptured aneurysms and about six to eight percent of all hemorrhagic strokes (Becske, 2014). SAH has a very poor prognosis with 10 to 15 percent dying before they reach the hospital and 25 percent die within 24 hours.

Survivors of intracranial hemorrhage are usually left with lifelong recovery and disability. Stroke is the leading cause of adult disability in the United States. For traumatic brain injury, the National Institutes of Health Consensus Development Panel estimates that 2.5 to 6.5 million Americans live with related disabilities. Risk for intracranial hemorrhage due to hemorrhagic stroke can be reduced by controlling risk factors, such as taking blood pressure medication as prescribed by a physician, limiting alcohol use, and avoiding illicit drugs. Risk reduction for traumatic brain injury can be reduced by using seat belts, avoiding driving under the influence of drugs and alcohol, wearing helmets, and taking measures to prevent falls in the home, hospital, or nursing home.

Legal Implications

Non-traumatic intracranial hemorrhage (stroke):

• For cases involving warfarin or Coumadin – was the patient’s lab work such as PT/INR adequately monitored? If the patient was suffering from Coumadin toxicity, what was the treatment?
• Was the blood pressure controlled according to guidelines?
• Did the patient develop hemorrhage after receiving treatment for ischemic stroke? If so, was the blood pressure controlled according to guidelines?

The most common cause of hemorrhagic conversion after giving a patient intravenous tPA (clot busting medications) for ischemic stroke is due to uncontrolled blood pressure.

Traumatic hemorrhage due to fall in an institution:

• Did the hospital or nursing home have a fall prevention program in place as required by the Joint Commission?
• Did the nursing home or hospital staff follow the fall prevention guidelines in the institution?
• Was a fall assessment completed?
• Was the fall assessment accurate?
• Was an accurate and complete admission assessment and health history completed and communicated?

Intracranial hemorrhages are seen in many cases ranging from child abuse to domestic violence and assault. The cause of the hemorrhage is typically associated with the trauma but there may be contributing factors such as drug or alcohol use, medical diagnoses, or medications. Any of these may increase the likelihood of bleeding and make a person more prone to a bleed or a bleed more severe than it would be otherwise. A review of the victim’s past medical history is needed to determine if any contributing factors exist.