INTRACRANIAL HEMORRHAGE

INTRACRANIAL HEMORRHAGES ARE CLASSIFIED ON THE BASIS OF BOTH

• LOCATION• UNDERLYING VASCULAR PATHOLOGY

DEPENDING ON LOCATION INTRAAXIAL & EXTRA AXIAL

INTRA AXIAL HEMORRAGE- - INTRA PARENCHYMAL - INTRA VENTRICULAR

EXTRA AXIAL HEMORRHAGE – EPIDURAL HEMORRHAGE - SUBDURAL HEMORRHAGE - SUBARACHNIOD HEMORRHAGE

INTRA PARENCHYMAL HEMORRHAGE

1. AETIOLOGY

A) HypertensionB) TraumaC) Cerebral amyloid angiopathyD) Advanced ageE) Cocaine and methamphetamine use

F) HEMORRHAGIC DISORDERSG) NEOPLASMSH) VASCULAR MALFORMATIONS

HYPERTENSIVE INTRAPARENCHYMAL HMRG

• SPONTANEOUS RUPTURE OF PENETRATING ARTERIES DEEP IN THE BRAIN

• SITES 1. BASAL GANGLIA 2.THALAMUS 3.CEREBELLUM 4.PONS

• FOCAL DEFICIT EVOLVE OVER 20- 30 MINUTES

• DIMINISHING LEVEL OF CONSCIOUSNESS

• SIGNS OF RAISED ICP

C/F

putamen

• C/L hemiparesis• Arm & legs gradually weaken• Slurred speech• Eye deviate away from side of hemiparesis

large – brain stem compression

Thalamic hemorrhage

• c/l hemiparesis• Prominent sensory deficit• Dominant thalamus – aphasia• Non dominant – constructional apraxia • Ocular disturbance- extension into upper

midbrain

Ocular disturbances• Deviation of eyes downward & inward• Unequal pupils with absence of light reactions• Ipsilateral horner’s syndrome• Paralysis of vertical gaze,nystagmus

Pontine hemorrhage

• Deep coma with quadriplegia over few minutes

• Pin point pupil reacting to light• Impaired reflex horizontal eye movements• Hyperpnoea,hyperhydrosis,hypertension are

common

Cerebellar hemorrhage

• Occipital headahe• Repeated vomiting• Ataxia• Dizziness and vertigo may be prominent

• Paresis of conjugate lateral gaze to the side of hemorrhage

• Ipsilateral 6th nerve palsy• Dysphagia,dysarthria

Cerebellar hmrg…

• Later stage – BRAIN STEM COMPRESSION/HYDROCEPHALUS

IMMEDIATE EVACUATION CAN BE LIFE SAVING !!

LOBAR HEMORRHAGE

• occipital hemorrhage - hemianopia; • left temporal hemorrhage,-aphasia and

delirium; • parietal hemorrhage - hemisensory loss; • frontal hemorrhage,-arm weakness • Focal headache and vomiting can occur

Cerebral amyloid angiopathy

• Elderly• arteriolar degeneration and

amyloid deposition• most common cause of lobar

hemorrhage in the elderly

• intracranial hemorrhages associated with IV thrombolysis given for MI

• patients who present with multiple hemorrhages (and infarcts) over several months or years

• patients with "micro-bleeds" seen on brain MRI sequences sensitive for hemosiderin

• pathologic demonstration of Congo red staining of amyloid in cerebral vessels

• no specific therapy, although antiplatelet and anticoagulating agents are typically avoided.

• Cocaine and methamphetamine are frequent causes of stroke in young (age <45 years) patients

Cocaine• enhances sympathetic activity • acute, sometimes severe, hypertension, • and this may lead to hemorrhage

• Intracranial hemorrhages associated with anticoagulant therapy can occur at any location• evolve slowly, over 24–48 hours

• hematologic disorders (leukemia, aplastic anemia, thrombocytopenic purpura) • multiple ICHs.• Skin and mucous membrane

bleeding offers a diagnostic clue

• Hemorrhage into a brain tumor may be the first manifestation of neoplasm

I. Choriocarcinoma,II. malignant melanoma, III. renal cell carcinoma, and IV. bronchogenic carcinoma are among the most common metastatic

tumors associated with ICH

Other causes

• Head injury• Hypertensive encephalopathy• Sepsis

VASCULAR ANOMALIES

Arterio venous malformations

• BLEEDING• HEADACHE• SEIZURES

• MRI / Contrast CT / Angiogram

• Treatment: Surgery / stereotaxic radiation

Venous anomalies

• As a result of anomalous cerebral, cerbellar / brainstem venous drainage• Are functional venous channels• Surgery – risk of venous infarction

and hemorrhage

Capillary telangiectasia

•May be associated with Hereditary hemorrhagic telangiectasia / osler rendu weber syndrome

• Typically : pons, deep cerebral white matter

Cavernous angioma

• tuft of capillary sinusoids within deep hemispheric white matter and brain stem with normal intervening neural structures

• < 1 cm diameter typically• a/w venous anomalies• Surgical resection reduce seizure risk and

bleeding risk

Dural ArterioVenous fistula

• connection b/w dural sinus and dural artery• Pulsatile tinnitus / headache • Surgical and endovascular techniques are

curative

INTRACEREBRAL HEMORRHAGE MANAGEMENT

• PROGNOSIS & CLINICAL OUTCOME –

ICH SCORING SYSTEM

EMERGENCY MANAGEMENT

• Airway managemant• Expansion of hemorrhage and elevated B.P ??• CURRENT RECOMMENDATION : “ KEEP CEREBRAL PERFUSION PRESSURE

ABOVE 60 mm Hg “ ( MAP – ICP )

ELEVATED ICP – • Tracheal intubation and acute

hyperventilation• Mannitol administration • Elevation of head end of bed• CSF drainage

• Blood pressure lowered with nonvasodilating IV drugs like nicardipine

• Cerebellar hematoma > 3 cm – evacuation <1 cm- surgical removal usually unnecessary1 cm – 3cm : carefully monitored

• Special attention to platelet count , PT, PTT to identify coagulopathy

EXTRA AXIAL HEMORRHAGES

(EDH, SDH,SAH)

EDH

• Most common – tempero parietal region• VESSELS : 1. Anterior & Posterior branches of

middle meningeal artery 2. Middle meningeal vein

‘’ lucid interval present ‘’

Kernohan’s notch effect

• EDH – RAISED ICP

CONING OF SUPRATENTORIAL CONTENT THROUGH THE TENTORIAL HIATUS

SHIFT OF MIDBRAIN TO THE OPPOSITE SIDE – INJURED BY SHARP END OF TENTORIUM CEREBELLI

CORTICOSPINAL TRACT ON OPPOSITE SIDE BEFORE DECUSSATION GETS INJURED

HEMIPARESIS AND PUPILLARY CHANGES ON THE SIDE OF HEMATOMA

C/F

• h/o trauma/ fall…Transient loss of consciousness..lucid interval…regain consciousness

• Pupillary changes – hutchinsonian pupil• Features of raised ICP

• X RAY & CT are diagnostic• Immediate surgical intervention is life saving

• Complications – meningitis, post traumatic amnesia,post traumatic epilepsy

Subdural hematoma

• Old age, h/o minor trauma• No lucid interval,severe primary brain damage• LOC immediately – progressive• 2 varieties : acute , chronic• Chronic – 2 – 4 weeks - chronic subdural hygroma

Treatment :• Craniotomy and clot evacuation• Antibiotics• Anticonvulsants for 3 years

• D/D – ICSOL , Electrolyte imbalance

SAH

• Sponateousnly / traumaCauses : ANEURYSM RUPTURE Hypertensiom AV malformation Blood dyscrasias anticoagulant therapy

C/F

• Features of raised ICP• SIGNS OF MENINGEAL IRRITATION• CRANIAL NERVES- 3,4,6• Pressure effect on surrounding structures

management

• Medical – adequate rest - analgesics and sedatives for headache -antifibrinolytics prevent rebleeding -dehydrating measures for brain -LP to relieve severe headache Surgery – aneurysm ( clipping of its neck ) / excision of AV malformation after 6-14 days

Questions????

THANK YOU