Intracerebral Hematomas


Background
  1. Hematomas that form deep within brain tissue
  2. 85% in frontal and temporal lobes
  3. Can occur with ALL degrees of severity of trauma
  4. Often multiple

Pathophysiology

  1. Usually result from shearing/ tensile forces
    • Stretch and tear deep small-caliber arterioles
    • Develop small petechial hemorrhages
    • These coalesce into a hematoma
  2. Combine with other injuries to cause mass effect/ herniation
    • Contusions
    • Other hematomas
    • Edema around lesions
  3. Clinical effects depend on
    • Size of hematoma
    • Location
    • If bleeding stops or is continuous
  4. Often not seen until hours/ days after injury
  5. Mortality
    • LOW if patient is conscious before surgery
    • Up to 45% if patient unconscious
    • HIGH mortality if:
      • Bleed into ventricles
      • Cerebellar hematoma

Diagnosis

  1. Clinical findings (Head trauma)
    • Decreasing mental status (50%)
    • Nausea/ vomiting (40-50%)
    • Headache (40%)
    • Seizures (6-7%)
    • Focal/ evolving neuro exam
      • Putamen
        • Contralateral: hemiparesis, sensory loss, conjugate gaze paresis
        • Homonymous hemianopia
        • Aphasia, neglect, apraxia
      • Thalamus
        • Contralateral: sensory loss, hemiparesis, conjugate gaze paresis
        • Homonymous hemianopia
        • Miosis, aphasia, confusion
      • Lobar
        • Contralateral: hemiparesis or sensory loss, conjugate gaze paresis
        • Homonymous hemianopia
        • Abulia, aphasia, neglect, apraxia
      • Caudate nucleus
        • Contralateral: hemiparesis, conjugate gaze paresis
        • Confusion
      • Brain stem
        • Quadriparesis, facial weakness
        • Decreased LOC
        • Gaze paresis, ocular bobbing
        • Miosis, autonomic instability
    • Cerebellum
      • Truncal ataxia
      • Ipsilateral: facial weakness, sensory loss
      • Gaze paresis, skew deviation
      • Miosis
      • Decreased LOC
    • Check for H/O HTN
    • Signs of incr ICP or herniation
      • Lethargy
      • Hypertension
      • Papilledema
      • Emesis
      • Cushing reflex (pre-terminal)
        • Bradycardia
        • Decreased RR
        • Hypertension
  2. Lab evaluation
    • Basic trauma panel
      • Hgb/Hct, WBC count, platelets
        • Serial Hgb/Hct not useful as screening test for occult bleeding
      • Basic chem panel
        • Electrolytes, glucose
        • BUN and creatinine
      • Amylase, transaminases
      • Coagulation studies
        • PT, PTT
      • Urinalysis
      • Type & cross
      • Toxicology screen
        • Serum AND urine
        • Serum ETOH level
  3. Diagnostic Imaging
    • Hyperdense areas
    • Well demarcated
    • Usually at frontal, temporal, or occipital poles
    • Surrounding edema/ mass effect
      • Midline shift
      • Herniation

Treatment

  1. ABCs
  2. Intubation (presume elevated ICP)
    • Pretreatment (2-3 minutes before intubating
      • Lidocaine: 1.5 mg/kg IV
        • To prevent incr ICP
      • Vecuronium; 0.01 mg/kg IV
      • Fentanyl: 3 mcg/kg IV (over 1 min)
    • Induction / Paralysis
      • Etomidate: 0.3 mg/kg IV
      • Succinylcholine: 1.5 mg/kg IV
    • See RSI Calculator
  3. Fluid resuscitation to treat shock
  4. Spine precautions
  5. Survey for additional injuries
    • Chest, abdomen
    • Spine, extremities
  6. Treat elevated ICP
  7. Treat Seizures
    • Acute seizures:
      • Lorazepam: 1 to 2 mg IV q 5 min up (max 4 mg)
      • Diazepam (0.1 mg/kg IV (up to 5 mg) q 5 minutes (max 20 mg)
    • Long-term or prophylactic Tx:
      • Phenytoin:
        • Load: 15-20 mg/kg IV (give at < 50 mg/min)
        • May follow with 100-150 mg after 30 min
  8. Definitive treatment
    • Surgical evaluation
  9. Further treatment
    • Optimize cerebral perfusion
      • Treat systemic shock
      • Treat hypoxia
    • Good general medical care
    • Monitor ICP and arterial pressure
      • Keep ICP < 20
      • Keep CPP < 70
    • Repeat head CT as needed

Disposition

  1. Neurosurgical decision
    • OR for evacuation
      • If GCS 3-9 with no other obvious cause
    • ICU observation with ICP monitoring
      • Small, stable hematomas