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) Hypertension
B) Trauma
C) Cerebral amyloid angiopathy
D) Advanced age
E) Cocaine and methamphetamine use
F) HEMORRHAGIC DISORDERS
G) NEOPLASMS
H) 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 unnecessary
1 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 / trauma
Causes : 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