Rupture of berry s aneurysmIntracerebral hematomas and subarachnoid hemorrhages can also result from strokes.PEAK AGEYounger than 20 yearsBimodal age 60 and older,50 yearsHISTORYFollowing injury, the patient may or may not lose consciousnessSubdural hematomas are divided into acute, subacute, and chronic, depending on the speed of their onset.Risk factors:1. Shaken baby syndrome2. Blood thinners(anticoagulants)3. Long-term alcohol abuse4. Dementia5. Elderly6. AlcoholicsSubarachnoid hemorrhage (SAH) range from subtle prodromal events to the classic presentation. Prodromal events often are misdiagnosed, while the classic presentation is one of the most pathognomonic pictures in all of clinical medicine.SIGNS & SYMPTOMS* Hypertension* Bradycardia* Bradypnea* Severe headache* Vomiting* SiizuresEDH has a classic three-stage clinical presentation that is probably seen in only 20% of cases. The patient is initially unconscious from the concussive aspect of the head trauma.The patient then awakens and has a lucid interval while the hematoma subclinically expands. As the volume of the hematoma grows, the decompensated region of the pressure-volume curve is reached, ICP increases, and the patient becomes lethargic and herniates. Uncal herniation from an EDH classically causes ipsilateral third nerve palsy and contralateral hemiparesis.* Loss of consciousness* Instability* Seizures* Disorientation* Ataxia* Altered breathing pattern* Blurred vision* Persistent headache,* Fluctuating drowsiness,* Confusion* Memory changes* Paralysis on the side of the body opposite the hematoma* Speech or language impairment* Severe headache with a rapid onset ("thunderclap headache")* Confusion or a lowered level of consciousness* Seizures* Photophobia* Focal neurologic deficit (hemiparesis, aphasia, hemineglect, cranial nerve palsies memory loss)* Motor neurologic deficits* Subhyaloid retinal hemorrhage & papilledema*| Temperature (secondary to chemical meningitis)*| Blood pressure* Neck stiffness usually presents six hours after initial onsetof SAH,* Isolated dilation of a pupil and loss of the pupillary light reflex may reflect brain herniation as a result of rising intracranial pressure * Oculomotornerve abnormalities (affected eye looking downward and outward and inability to lift the eyelid on the same side) or palsy,* "sympathetic surge" i.e. overactivation of the sympathetic systemGRADINGNilBender grading systemWorld Federation ofNeurosurgeons (WFNS)classification:Group 1Normal mental function, no focal signsGradeGCSFocalneurologicaldeficitGroup 2Lethargic, focal neurologic signsGroup 3Stuporous,marked focal neurologic signs115Absent213-14Absent313-14PresentGroup 4Coma, sign of hibernation (pupilary dilation, decerebrate or decorticate posturing, respiratory arrest)47-12Present or absent5 1 cm, midline shift >5 mm, or GCS drop by two or more points from the time of injury to hospitalization. Nonoperatively managed hematomas may stabilize and eventually reabsorb, or evolve into chronic SDHsPrompt neurosurgery or radiologically guided interventions with medications and other treatments to help prevent recurrence of the bleeding and complications. Many aneurysms are treated by a less invasive procedure called "coiling", which is carried out by instrumentation through large blood vessels.MORTALITY15 and20%30% overall, 60 to 80% in acute SDHUp to half of all cases of S AH are fatal and 10-15% of casualties die before reaching a hospitalPOORPROGNOSIS* Advanced age* Intradural lesions* Temporal location* Increased hematoma volume* Rapid clinical progression* Pupillary abnormalities* Increased intracranial pressure* Lower Glasgow coma scale (GCS)* No lucid interval* Acute subdural hematomas* Glasgow coma scale 80* Acute duration* hypodensity of SDH on CT scan">