Spontaneous intracerebral hemorrhage By: You Xinli International Medical University, Malaysia May 2008 Case Summary A 57 year-old lady with history of hypertension and hyperlipidemia presented to the accident and emergency department complaining of sudden onset of severe headache, giddiness, neck stiffness and generalized weakness. There were no history of trauma, syncope, seizures, nausea, vomiting, fever, photophobia or previous episodes of similar attacks. Her family and social history were unremarkable. Physical examination revealed an elevated pulse and blood pressure of 150/100, Glasgow coma scale of 15, right homonymous hemianopia, and a 3/5 motor function of the right limbs. Spontaneous intracerebral hemorrhage was suspected. Computerized tomographic (CT) scanning of the brain without administration of contrast material, was subsequently performed. Axial CT scan Findings Day 1 A 5.5 x 3.0 cm hyperdense area seen in the left parieto-occipital lobe is suggestive of an intra- parenchymal hematoma. It is accompanied by an area of low attenuation which suggests an area of perilesional oedema. Intraventricular bleed is noted. There is also 2mm midline shift towards the right and sulcal effacement along the left parietal region. Day 6 Interval changes in the size of the left parietal intraparenchymal haematoma with accompanying reduction in intensity is noted. Mass effect remained unchanged. Day 11 Hematoma noted is smaller in size and has a reduction in density. There is reduction in perilesional oedema and mass effect. Day 16 Hematoma noted is smaller and has decreased in density. The perilesional oedema and mass effect has reduced. Incidental Finding A 1.8 x 1.1 cm hypodense lesion is seen on the left side of the cervicomedullary junction. Suspected to be an incidental arachnoid cyst. 4 vessel cerebral angiography was then indicated as the location of the hematoma was suspicious of an underlying vascular malformation. Cerebral angiogram showed : A small arteriovenous malformation in left parieto- occipital region arising from the distal branch of the left MCA, beyond the M2 segment, with early draining vein to superior sagittal sinus. No aneurysms were seen. In conclusion, a diagnosis of left occipito-parietal hemorrhage secondary to arteriovenous malformation was made. Spontaneous Intracerebral Hemorrhage ( SICH) An Introduction Definition: SICH is defined as blood clot in brain parenchyma in the absence of trauma or surgery.3 Epidemiology: 15-20% of all strokes in western world with higher incidence in Asia.1 30 day mortality is 45%.1 Circadian pattern of SICH onset in the morning has been reported2 and postulated to occur coincidentally with increased sympathetic tone or arterial blood pressure in the morning.3 *3 major causes of SICH Etiology Primary means Salient points of diagnosis Hypertension Clinical •Uncontrolled hypertension causes arteriosclerosis which leads to (Most significant Diagnosis rupture of small (50-200 μm) arterioles. cause of primary SICH 3) •Presents as non-lobar hemorrhages (putamen, pons (perforating arteries of the basilar artery), thalamus (thalamoperforating arteries) , cerebellum (superior and anterior inferior cerebellar arteries) , and brainstem). Etiology Primary means Salient points of diagnosis Amyloid angiopathy Clinical •Deposition of beta-amyloid protein and degenerative changes in Diagnosis, cortical and leptomeningeal vessel wall; rupture of small and Biopsy for medium-sized arteries. confirmation •>70 years old. •Presents as lobar hemorrhages. Etiology Primary means Salient points of diagnosis Vascular anomalies Imaging •Rupture of AVM. AVM are focal abnormal conglomerations of • Arteriovenous Studies dilated arteries and veins in the brain parenchyma. AVM lacks a malformation capillary bed, hence this leads to abnormal arteriovenous (AVM) shunting.. •Young patients. •Presents as lobar hemorrhages. •Recurrent hemorrhage of 18 %/year; risk is reduced by surgical excision, embolization, and radiosurgery4 Pathophysiology of SICH ** Therapeutic targets Evaluation History : Decreased level of consciousness Increased intracranial pressure and the direct compression or distortion of the thalamic and brain-stem reticular activating system4 Headache, Vomiting Increased intracranial pressure Hypertension Signs of meningsims (Hemorrhage in the ventricles) Physical examination Specific neurologic deficit4 Contralateral sensory-motor deficits of varying severity Supratentorial intracerebral hemorrhage in the putamen, caudate, and thalamus with involvement of internal capsule Higher level cortical dysfunction (aphasia, hemianopia) Disruption of connecting fibers in the subcortical white matter and functional suppression of overlying cortex Signs of brain-stem dysfunction (abnormal gaze, cranial nerve deficiets , contralateral motor deficits.) Infratentorial intracerebral hemorrhage Laboratory Complete blood count Coagulation parameters Serum electrolytes Liver function tests Drug Screen Additional investigations required by patient’s comorbidities Imaging Computerized tomography(CT) scanning of the brain Initial diagnostic procedure Define: Size, location and extent of hemorrhage Suggests potential causes ( vascular anomalies, and tumor) Presence of complications ( intraventricular extension, edema, hydrocephalus, and signs of herniation) Without administration of contrast medium Hemorrhage volume as predictors of outcome Magnetic Resonance Imaging Best for identification of Brain Tumors Cavernous malformation Multi-sequence MR imaging for assessment of hyperacute SICH Appearance of SICH depends on hemoglobin breakdown products Cerebral Angiography Tool for definitive diagnosis on vascular abnormality Site of hemorrhage, age, patient’s co-morbidities and clinical status, and institutional diagnostic yield to be considered beforehand Management Initial General medical care Targeted care Medical Surgical Rehabilitation Management Initial General medical care 1. Emergency stabilization of airway, breathing, and circulation. Targeted care 2. Early differentiation between Medical cerebral infarction and intracerebral hemorrhage for consideration of Surgical immediate thrombolytic therapy. Rehabilitation Management 1. Hourly evaluation of Glasgow coma scale. - instability is highest during the first 24 hours Initial after the onset of an intracerebral hemorrhage.4 General medical care 2. Blood pressure management. Targeted care -Hypertension is associated with expansion of the hematoma and poor prognosis4 Medical -initiate treatment when > 180/105 mmHg with agents such as labetalol, enalapril, Surgical nitroprusside and nicardipine as recommended by Current American Heart Rehabilitation Association (AHA) guidelines.5 3. Appropriate management of seizure. 4. Tight glycemic control (<5.2 mmol/L) and maintenance of normothermia (<38.5oC) Management Initial General medical care Targeted care Aim : To minimize secondary injury Medical 1. Correct coagulopathies and coagulation parameters as quickly as possible. Surgical 2. Early intervention to lower ICP gradually. Rehabilitation Management Initial Aim: Removal of clot and mass effect. General medical care 1. Initiate resolution of hematoma by infusion Targeted care of fibrinolytics via the ventriculostomy. Medical 2. Surgical removal of hematoma by craniotomy. Surgical 3. Patients with hydrocephalus should receive Rehabilitation an intraventricular catheter for external drainage. Management Initial General medical care Targeted care 1. Less than 20% are independent at 6 months after SICH.6 Medical 2. Aimed to assist patients to regain maximal Surgical function and psychological acceptance. Rehabilitation Acknowledgement Case contributed by : Dr. Elizabeth Chia, Dr. Lynette Teo. References 1. Wai S. Poon, C. Avezaat, M. Intracranial Pressure and Brain Monitoring XII: V. 12. Changes in cerebral hemodynamics and cerebral oxygenation during surgical evacuation for hypertensive intracerebral putaminal hemorrhage. Page 97. 2. Gallerani M, Trappella G, Manfredini R, et al: Acute intracerebral haemorrhage: circadian and circannual patterns of onset. Acta Neurol Scand 89:280–286, 1994 3. Matthew E. Fewel, M.D., B. Gregory Thompson, jr., M.D., and Julian T. Hoff, M.D. Spontaneous intracerebral hemorrhage: a review. Neurosurg Focus 15 (4):Article 1, 2003. 4. Adnan I.Qureshi, M.D, Stanley Tehrim, M.D, et al; Spontaneous Intracerebral Hemorrhage, A review article. N Engl J Med, Vol. 344, No. 19, May 10, 2001 5. Association AH. Advanced Cardiac Life Support Guidelines: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. 2005, in press. 6. Edward C. Jauch, MD, MS. Intracerebral Hemorrhage. Foundation for Education and Research in Neurological Emergencies.