INTRACEREBRAL HEMORRHAGE

							INTRACEREBRAL
 HEMORRHAGE




                 Piotr Szczudlik MD
                   Marcin Żach, MD
           Department of Neurology
        Medical University in Warsaw
 Intracerebral hemorrhage
• DEFINITION
  Arterial bleeding into the parenchyma of the brain
• ETIOLOGY
  Hypertension (>50% cases)
  Amyloid angiopathy (in the elderly, 30% cases)
  Anticoagulation / thrombolytics
  Neoplasms
  Drug related
  Aneurysm / arteriovenous malformation
  Vasculitis
  Idiopathic
   Intracerebral hemorrhage
• Blood undergoes a series of changes
  Fluid
  Coagulation within hours
  Phagocytosis of RBC starts within 24h
  Hemosyderin and hematoidin appear within days
  Smooth walled cavity is formed in 2-3 months
• Hematoma is surrounded by petechial
  hemorrhages and edema
   Intracerebral hemorrhage
• Small
     1-2cm in diameter
     2ml in volume
• Massive hemorrhage
     several cm in diameter
  With or without rupture into ventricular
  system
             Hypertensive ICH
• Lipohyalinosis, microaneurysms of
  penetrating arterioles 50-200m in diameter
  •   lenticulostriate
  •   thalamoperforate
  •   paramedian basilar branches
  •   small branches of the superior and anterior
      inferior cerebellar arteries
             Hypertensive ICH
• Most common sites of ICH
  •   putamen and adjacent internal capsule
  •   thalamus
  •   cerebellar hemisphere
  •   the pons
  •   the central white matter of the temporal,
      parietal or frontal lobes (lobar hemorrhages)
             Hypertensive ICH
• Most often without warning signs, while patient is
  awake, often after exertion
• No age and sex predilection
• Clinical presentation:
   •   Headache
   •   Vomiting
   •   Decreased level of consciousness
   •   Elevated BP
   •   Neurological deficit varies with the location and severity
       of bleeding
    Glasgow Coma Scale (GCS)
Eyes opening           Never                              1
                       To pain                            2
                       To verbal stimuli                  3
                       Spontaneous                        4

Best verbal response   No response                        1
                       Incomprehensible sounds            2
                       Inaproprate words                  3
                       Disoriented and converses          4
                       Oriented and converses             5

Best motor response    No response                        1
                       Extension                          2
                       Flexion                            3
                       Withdrawal                         4
                       Localises pain                     5
                       Obeys                              6
   TOTAL                                           3-15
            Hypertensive ICH
• Putaminal hemorrhage

  •   Hemiplegia or hemiparesis
  •   Hemisensory loss
  •   Visual field disturbances
  •   Aphasia or neglect syndrome (depending on
      side of bleeding)
            Hypertensive ICH
• Lobar hemorrhages
  • Depending on site of bleeding

• Thalamic hemorrhage
  •   Hemiplegia or hemiparesis
  •   Severe sensory deficit
  •   Aphasia or neglect syndrome
  •   Ocular disturbances
            Hypertensive ICH
• Pontine hemorrhage
  • Quadriplegia
  • Coma
  • Pinpoint pupils


• Cerebellar hemorrhage
  •   Develops over period of several hours
  •   Headache
  •   Vertigo
  •   Inability to sit, stand or walk
        Nonhypertensive ICH
• Cerebral amyloid angiopathy (CAA)
  • Important cause of lobar hemorrhages in the
    elderly
  • Patients typically aged >60 and normotensive
  • Familiar forms of CAA in 3rd to 5th decade
  • Amyloid deposits in media and adventitia of
    medium and small arteries of brain hemispheres
          Nonhypertensive ICH
• Anticoagulation
  •   Warfarin, acenocoumarol
  •   Excessive dose
  •   Underlying lesion (cerebral infarction)
  •   Uncontrolled hypertension
  •   Mechanism unclear
• Thrombolytic agents
  • Streptokinase, urokinase, rtPA
  • Dose related
         Nonhypertensive ICH
• Drug abuse
   •   Cocaine
   •   Metamphetamine
   •   Amphetamine
   •   Methylphenidate
   •   Phencyclidine
• Elevation of blood pressure
• Vasospasm (ischemia followed by reperfusion)
• Ethanol (platelet and coagulation abnormalities)
        Clinical course of ICH
• 30-35% of patients die within 30 days
• Hemorrhages 60ml and initial GCS8 –
  mortality 90%
• Death due to raised ICP
• Raised ICP causes shift or herniation of tissues
  through dural compartments and fatal brain stem
  compression
• Raised ICP compromises cerebral blood flow
       Clinical course of ICH
• Atrophy (common in the elderly) can
  provide reserve room for local volume
  expansion
• Hydrocephalus (acute or subacute) may
  complicate clinical course
       Diagnostic procedures
• Computed tomography
• CT angiography
• Magnetic resonance imaging
• MR angiography
• Conventional angiography (Digital
  Subtraction Angiography)
• CSF examination
           Treatment of ICH
• General medical management of comatose patient
• Ventilation
• Monitoring and controling of ICP (Mannitol IV,
  Furosemid IV, controlled hyperventilation with
  pCO2 25-30mmHg)
• Rapid reduction of BP not recommended (cerebral
  perfusion)
• Sustained MBP >110mmHg increases edema and
  risk of further bleeding
Surgery in ICH
Specific treatment of ICH
       Treatment of complications
• Brain edema / increased ICP
• Seizures
• Hydrocephalus
• Pulmonary (aspiration, pneumonia)
• Cardiovascular (MI, arrhythmias, congestive heart
  failure, DVT, pulmonary embolism)
• Gastrointestinal (stress ulcers, bleeding, dehydration,
  malnutrition, constipation)
• Urinary (infection, incontinence)
• Skin (pressure sores, contractures)
     Treatment of raised ICP
• Removing the cause (surgery, drainage)
• Avoidance of hypercapnia, hypoxia and
  hyponatremia
• Avoidance of pyrexia
• Avoidance of extremes of BP (impared
  autoregulation)
• Controlled hyperventilation
• Elevated head position
         Treatment of seizures
• Prophylactic antiepileptics not
  recommended