Intracranial Hemorrhage

• Rupture of middle meningeal artery often 2° to skull fracture
• Lucid interval
• Transtentorial herniation, CN III palsy
• Does not cross suture lines – lentiform

• Rupture of bridging veins
• Shaken baby syndrome
• Crosses suture lines and can cause midline shift – crescent shape

• Rupture of saccular aneurysm or arteriovenous malformation
• “Worst headache of my life”
• Bloody or yellow spinal tap (xanthochromic)
• 4-10 days after hemorrhage à vasospasm à ischemic infarct à nimodipine used for prevention
• Most common is AComm and ACA

• Most commonly caused by systemic hypertension; also seen in amyloid angiopathy
• Chartcot-Bouchard aneurysm of lenticulostriate vessels
• Typically occurs in basal ganglia/internal capsule

Subarachnoid hemorrhage

• A retrospective analysis of patients with subarachnoid hemorrhage (SAH) suggests that minor episodes with sudden headache may precede rupture of an aneurysm. Up to 40% of patient will experience a sentinel headache a week or more prior to rupture of a cerebral aneurysm. This woman’s history is compatible with sentinel headache for a “leaking” aneurysm. Risk factors for the development of SAH are 1) smoking, 2)hypertension, and 3)alcohol, 4)estrogen depletion. Variant migraine includes such findings as hemiplegia, brain stem symptoms (vertigo, etc.), transient blindness, ophthalmoplegia, not present in this woman. Giant cell arteritis is associated with  unilateral temporal headache, jaw claudication, and possible symptoms of retinal ischemia, not manifested in this woman. Cerebral vasospasm is a complication of SAH leading to neurologic decline in the days following the SAH.

• Epidural hematoma, usually caused by a middle meningeal arterial bleed, occurs between the dura mater and the inner table of the calverium. The classic triad of trastentorial herniation includes decerebrate posturing (extension of the arm at the elbows with internal arm rotation), a fixed and dilated pupil on the side of the herniation, and coma. Decerebrate posturing indicates neurologic damage at or below the midbrain. Decorticate posturing indicates severe neurologic damage in the hemisphere above the midbrain; and is clinically typified by arm flexion and fist clenching.