A19. Intracerebral bleedings Flashcards
Intracerebral hemorrhage (ICH) definition
- Bleeding within the brain parenchyma
Intracerebral hemorrhage is most common in patients with
- hypertension
Intracerebral hemorrhage is a type of
- type of hemorrhagic stroke,
accounts for 10% of strokes
30 day prognosis in patients diagnosed with Intracerebral bleedings
approximately half of patients
die within 30 days.
Hemorrhagic stroke
definition
Rupture of a blood vessel within the brain or the cerebrospinal fluid
Hemorrhagic stroke subtypes
- Intracerebral hemorrhage (intraparenchymal hemorrhage): bleeding within the brain parenchyma
- Subarachnoid hemorrhage: bleeding into the subarachnoid space
- Intraventricular hemorrhage: bleeding within the ventricles
Intracerebral hemorrhage can it rupture? what happens?
Can rupture through to the cortical surface to produce
* associated SAH (Subarachnoid hemorrhage )
or
* into the ventricular system. (30%)
Intracerebral hemorrhage most commonly affects which structures of the brain?
Most commonly affects the deep structures of the brain
common sites of intracerebral hemorrhage in hypertensive patients
hypertensive patients 70% occur in the basal ganglia/thalamic region
common sites of intracerebral hemorrhage In normotensive patients
- 37% occur in basal ganglia/thalamic region
- frontal,
- temporal,
- parieto-occipital,
- cerebellar and
- pontine areas.
Supratentorial hematomas can have
mass effect
(sudden headache with deteriorating consciousness)
and focal signs.
Intracerebral hemorrhage in Basal ganglia symptoms
Hemiparesis,
sensory loss,
eye deviation
symptoms of ICH(intracerebral) in Thalamus
- Sensory loss,
- later hemiparesis,
- gaze disturbance
Lobar ICH(intracerebral) prognosis
Better prognosis, intraventricular bleeding is rare
Cerebellar ICH (intracerebral)
- Nausea
- ataxia,
- dizziness,
- signs of brainstem compression (30% mortality)
signs of brainstem compression is seen in
cerebellar intracerebral hemorrhage
symptoms of ICH(intracerebra) in Pons
- Fast progressing hemi- or tetraparesis
- disturbed eye movements,
- decerebration,
- small pupils
- disturbance of breathing
- coma
- death (high mortality)
Intracerebral hemorrhage etiology
A. Nontraumatic
● Hypertension - Most common cause of spontaneous ICH, vessel wall lipohyalinosis and
Charcot-Boucard microaneurysms
● Cerebral amyloid angiopathy - Beta-amyloid in vessel walls
● Ruptured arteriovenous malformations - Excessive strain
● Vasculitis (e.g. giant cell arteritis)
● CNS infections (e.g. HSV encephalitis) and septic emboli
● Coagulation disorders (e.g. , hemophilia, anticoagulant use)
● Neoplasms (e.g. meningioma)
● Stimulants (e.g. cocaine, amphetamines) possibly also caffeine
● Infarctions (venous sinus thrombosis, hemorrhagic)
● Ischemic stroke (due to reperfusion injury)
B. Traumatic brain injury - Vessel damage
C. Idiopathic
why is hypertension the most common cause of spontaneous ICH
Hypertension-induced hemorrhages typically occur in the subcortical regions.
Small penetrating arteries supply this part of the brain and emerge at sharp angles from larger vessels, making them particularly sensitive to changes in blood pressure.
most common cause of spontaneous ICH in individuals > 60 years of age
Cerebral amyloid angiopathy
most common cause of spontaneous intracerebral hemorrhage in children
Arteriovenous malformations
how can meningioma cause ICH
due to the invasion of vessels by tumor cells
or
malignancy-associated coagulopathy
Intracerebral hemorrhage Pathological effects
● Space-occupying effect → Brain shift
● Continued bleeding → Expanding may continue beyond the first few
hours.
● Within 48 hours:
disruption of BBB,
vasogenic and cytotoxic edema, neuronal damage and
necrosis
● Resolution in 4-8 weeks → Cystic cavity
Pathological effects of ICH within 48 hrs
Within 48 hours:
* disruption of BBB,
* vasogenic and cytotoxic edema,
* neuronal damage and
* necrosis
Symptoms of ICH
Usually worsen rapidly (minutes-hours)
● Severe headache
● Nausea
● Vomiting
● Confusion
● Loss of consciousness
● Focal deficits depending on the etiology, location and size of the hemorrhage
Focal deficits in ICH depend on
depending on the
* etiology,
* location and
* size of the hemorrhage
Intracerebral hemorrhage (ICH) diagnostics
● Noncontrast CT - solitary hyperdense lesion, surrounded by
hypodense edema (most commonly within basal ganglia or
internal capsule)
● Once hemorrhage is confirmed:
- Laboratory tests (CBC,
coagulation parameters, blood glucose levels)
- Angiography (malformations, vasculitis)
findings on non contrast CT in ICH
- solitary hyperdense lesion,
- surrounded by hypodense edema (most commonly within basal ganglia or internal capsule)
ICH treatment
Great variation due to lack of proven medical/surgical treatment for ICH.
A. Acute stabilization and ICP control
-a. Fluid replacement
-b. Consider intubation with hyperventilation
-c. Head elevation
B. Medical therapy
a. Control blood pressure (e.g. i.v. labetalol, nicardipine, enalapril or hydralazine)
b. Maintain normal blood glucose
c. Monitor anticoagulation parameters. If due to oral anticoagulant therapy, suspend this
and administer vitamin K and vitamin-K dependent coagulation factors.
d. Tranexamic acid?
C. Surgical intervention
a. No evidence to support routine surgical evacuation
drugs used in ICH to Control blood pressure
i.v. labetalol,
nicardipine,
enalapril
or hydralazine
what t do If ICH is due to oral anticoagulant therapy
suspend anticog theraoy
and
administer vitamin K and vitamin-K dependent coagulation factors
when is Surgical intervention considered in ICH
Should be considered for
* supratentorial hemorrhage with mass effect
or
* for posterior fossa/cerebellar hematoma to release brainstem compression (Immediate if signs of
herniation!)
Surgical procedures in ICH
- Decompressive craniotomy,
- Hematoma evacuation
Hematoma evacuation indications
- in patients with infratentorial hemorrhage who have any of the following:
*Large hematoma (> 3 cm)
*Declining neurological status
*Hydrocephalus
*Signs of brain herniation (e.g., Cushing triad) - Consider in patients with supratentorial hemorrhage and a declining GCS score or an initial GCS score of 10–13
indication of Decompressive craniotomy
- Refractory elevated ICP
- Large hematoma with a significant midline shift
- GCS score ≤ 8
Complications of ICH
● Repeat hemorrhage
● Vasospasms
● Deep vein thrombosis
● Dysphagia (can lead to aspiration pneumonia)
● Elevated ICP → Brain herniation
● Seizures
● Hydrocephalus
● SIADH
Evacuation of the hematoma may be appropriate depending on
the
* size,
* location,
* and associated clinical features of the ICH.
Once hemorrhage is confirmed by non contrast CT what additional tests are done
- Laboratory tests
*CBC,
*coagulation parameters,
*blood glucose levels), - Angiography
(malformations, vasculitis)
symptoms of ICH usually worsen —-
rapidly (minutes-hours)
