How to diagnose intra cerebral hemorrhage
Intra cerebral hemorrhage, means bleeding inside the brain. Diagnosis is based on clinical features and radiological investigations. Clinical features change depending on the site and the rate of bleeding. To understand the rest of the article one must know basic anatomy of the human central nervous system.
Human central nervous system is divided into three compartments. They are brain, brain stem, and spinal cord. The human brain is enclosed in rigid enclosure called the skull. So bleeding inside the brain increases intracranial pressure.
Entire central nervous system is covered by three distinct membranes called meninges. They are Dura mater, Arachnoid mater, and pia mater (from outer to inner). Pia mater is firmly attached to the brain. Cerebrospinal fluid exists between pia and arachnoid mater. Dura mater is the outer most layer. The brain consists of solid areas as well as fluid filled areas called ventricles. The brain stem passes through opening called foramen magnum in skull and continue as the spinal cord. The brain stem has vital areas like the respiratory center. Blood is supplied to the brain from the arteries and taken out from the veins.
Main causes of intra cerebral hemorrhage are ruptured blood vessels, tumors, and trauma.
Most common clinical features are due to raised intra cranial pressure. Most significant symptom is a worsening headache when moving and early morning headache. Sometimes, the patient wakes up due to a severe headache. If the bleeding is quick, then the patient will quickly develop a very severe headache (worst headache ever), loss of consciousness, fits, respiratory arrest and coma. If the bleeding is slow (especially in venous bleeding) clinical features deteriorate slowly. After complaining, doctor will look at the patient’s eyes with an ophthalmoscope to detect papilledema.
Clinical features also depend on the site of the bleeding
Extra dural (outside the dura mater)
The patient’s clinical features appear gradually. Usually occur due to accidents. Initially patient will be perfectly normal. Then blood pressure will go up and pulse will go down (Cushing’s reflex). Pupils of the eye will dilate, after that patient might develop fits. Usually patients deteriorate within six to eight hours after the accidents. So doctors tend to admit suspicions patients to the ward and monitor. CT scans can diagnose the problem accurately.
Chronic Sub Dural hemorrhage (SDH)
These usually occur in elderly patients, without a history of an accident. It is a venous type of bleeding. Patients deteriorate over six to seven days. Clinical features are gradual decline of personality (socially disinhibition), urinary incontinence, drowsiness, inattentiveness, incoherent thoughts and incoherent speech. It is important to consider SDH, in any elderly patient, complaining above features. CT scan can diagnose accurately.
Sub arachnoid hemorrhage
Patients presents with severe headache, neck stiffness, and loss of consciousness. Prognosis is bad. It is usually due to a spontaneously ruptured blood vessel.
Intra cerebral hemorrhage due to other causes
Gradual development of symptoms of raised intracranial pressure is the most common. Additionally patients will have localized signs such as paralysis of one limb, partial seizures, and partial sensory loss.
Almost all causes of intra cerebral hemorrhage can be diagnosed by CT (Computerized tomography) or MRI (Magnetic resonance imaging) scans.