Intracerebral haemorrhage

Question 1

What is an intracerebral haemorrhage?

Answer 1

acute extravasation of blood into the brain parenchyma

Question 2

What are the causes of ICH?

Answer 2

-htn (most common) - usually involves small, deep arterial branches - typically basal ganglia - (caudate, thalamus), pons, cerebellum
-amyloidosis - amyloid peptides deposit into walls of blood vessels causing weakened areas of friable tissue - typically cortical bleeds - cerebrum & cerebellum
-coagulopathy - including post thrombolysis - anticoag drugs or liver failure
- mycotic aneurysm secondary to bacterial endocarditis- Infective vegetations break off and lodge in cerebral circulation causing damage to vessel wall which balloons off
-bleed into tumour- malignant cells disrupt blood brain barrier & blood cells seep into brain tissue around the mass
- bleed into infarct - alteplase, reperfusion injury - blood vessels damaged by inflammation from infarcted tissues - causes weakening of vessel walls
-cerebral venous sinus thrombosis - blocked venous drainage causes back up of blood proximal to clot and vessels rupture causing bleeding, usually around the edges of the cortex
-AVM

Question 3

Symptoms of ICH

Answer 3

Headache - blood irritates meninges (esp cortical bleed)
Focal neuro deficits
N&V
Decreased LOC
High ICP - munroe kelly doctrine

Question 4

Risk factors for ICH

Answer 4

-Htn
-cocaine use
-amyloidosis
-alcohol abuse
-antiplatelet or anticoag therapy

Question 5

Imaging

Answer 5

CTH - non contrast - look for bleed, midline shift, hydrocephalus due to intraventricular haemorrhage
CTA - esp in young patients
Later MRI - vascular malformations
TTE - if suspicion of IE

Question 6

How to manage ICH

Answer 6

A &B - Itubate as needed
- Neuroprotective ventilation - PaO2 >10, PaCO2 4.5-5
C - Aim SBP 160-180 - use labetalol as needed
D- monitor pupils +/- neurology
Neuroprotective measures
E - if on anticoags, liase with haematology and correct as appropriate