44 terms

Intracerebral Hemorrhage

Dr. Freakin DLG

Terms in this set (...)

Nontraumatic Intracranial Hemorrhages
-Intracerebral hemorrhage (ICH)-aka intraparenchymal hemorrhage
-Subarachnoid hemorrhage (SAH)
Traumatic Intracranial Hemorrhage
-not considered types of stroke
-Contusion, subdural hematoma, epidural hematoma
Ischemic stroke
most common type of stroke - 85%
intracerebral hemorrhage
second most common type of stroke - bleeding into brain - 10%
-w/ ischemic makes focal brain dysfxn
Subarachnoid hemorrhage
least common stroke cause - 5%
-bleeding around brain
-w/ intracerebral hemorrhage = diffuse brain dysfxn
Findings in Intracerebral hemorrhage
Due to Increase ICP
-headache, nausea, vomiting, decrease conciousness

Due to focal lesion
-Focal signs such as hemiparesis
General features of Intracerebral hemorrhage
-Mass lesion of acute onset
-Focal lesion w/ mass effect causing - compression of adjacent structures + increase in ICP
-Specific deficits dependent on - location of hemorrhage origin, surrounding structures (parenchyma-edema, ventricles-intraventricular hemorrhage)
Chronic hypertension
Intracerebral hemorrhage usually caused by?
-long term damages small penetrator arteries in middle part of brain and brainstem (putamen, thalamus, pons, cerebellum)
Non-hypertension causes of Intracerebral hemorrhage
More likely if no past hx of HTN; lobar location (peripheral)

-Include tumor, arteriovenous malformation (AVM), amyloid angiopathy, bleeding disorder
Intracerebral Hemorrhage nonmodifiable risk factors
-Advanced Age
-African American Heritage (culture-diet)
-Japanese Heritage( low-chol diet, hypertension)
Modifiable Risk Factors of Intracerebral Hemorrhage
-Cig smoking
-OH ingestion
-Sympathomimetic drugs
Intracerebral Hemorrhage due to Chronic Hypertension
-50% of all cases
-damaged small arteries in medial brain or brainstem
-Pathologic theories: Charcot-bouchard aneurysm, arterial wall path
4 most common location sof ICH due to Chronic Hypertension
1.) Putamen (basal ganglia)
2.) thalamus
3.) pons
4.) cerebellum
Putaminal (ICH) (basal ganglia)
-Hemisensory deficit
-Homonymous hemianopsia
-Ipsilateral gaze deviation
-Aphasia (neglect)
Thalamic Hemorrhage
-Hemisensory deficit
-Aphasia (neglect)
-Eye findings (horner syndrome -ips, Gaze palsies - vert/horz, pupil light-near dissociation

Effects surrounding structures!
-internal cap (weakness), hypothalamus (horner), dorsal midbrain (gaze & pupil abnormalities)
Pontine Hemorrhage
-latera gaze palsies
-decerebrate posturing
-Internucleur opthalmoplegia
-Pinpoint reactive pupils
-Resp abnormalities
-Cardiac arrhythmias
-Hyperreflexia/babinski signs
Cerebellar Hemorrhage
-Gait and/or limb ataxia
-Impaired consciousness
-Diplopia/disconjugate gaze
-Gaze palsies/ nystagmus
-Small reactive pupils
-Facial weakness
-Hyperreflexia / babinski signs

effects cerebellar, pons, & 4th ventricles
-squish basilar artery into the clivus***
4 factors associated w/ poor prognosis
-The ICH score
1.) Age > 80
2.) Volume > 30 cc
3.) brainstem/cerebellum origin
4.) decrease consciousness

3 or less = good prognosis
4 or more = bad
Lobar ICH etiologies
-amyloid angiopathy
-vascular malformation
-aneurysm (multiple types)
-HTN encephalopathy
-Cerebral vein thrombosis
-Bleeding diathesis
-Moyamoya disease
-Chronic hypertension
Amyloid (congophilic) Angiopathy
-Elderly pts > 65; increases w/ age
-2% of all ICHS
-Cortical and Meningeal arterioles/arteries = fragile due to 1.) amyloid deposits, 2.) microaneurysms and fibrinoid degeneration
-NOT associated w/ systemic amyloidosis
-may present w/ multiple lobar ICH
Vascular Malformations
-Arteriovenous malformation
-Cavernous Malformation
-Venous malformation
-Anrteriovenous Fistula

tx = resect, embolize; no intervention!
Arteriovenous Malformatoin
-Arteries and veins communicate directly w/ intermixed gliotic brain tissue
-ICH occurs due to high Pressure in draining vein
-usually solitary, vary in size, congenital
Cavernous Malformation
-Dilated venous structures, low bleeding rate
-often multiple angiographically occult; congenital
Venous Malformation
-only venous elements, usually in deep white matter; often multiple, congenital
-capillary origin; very small; often multiple, congenital
Arteriovenous Fistula
-Direct artery vein-connection; congenital or post traumatic
Saccular (berry) Aneurysms
-occur in 2-5% of population
-25% have > 1 aneurysm
Fusiform Aneurysms
-aka dolichoectatic (long and twisting)
-usually cause compressive symptoms, not ICH
Infectious Aneurysms
-due to septic emoblus, usually from endocarditis
-usually bacterial, fungal less common; tx w/ antibiotics
Other kinds of aneurysms
Primary-may result in ICH

-most commonly cause ICH
-Usually in distal deep white matter
-Ones that bleed ("Menstrual Cycle Time Rate") - Melanoma, Thyroid, Renal, choriocarcinoma
-most common in our society = breast and lung
Hypertensive Encephalopathy
-Acute HTN outstrips cerebral autoregulation and causes blood-brain-barrier disruption w/ resultant vasogenic edema and possible ICH
-may occur at lower BP than expected
-delirium, decrease consciousness, seizures
-MRI and CT - white matter (vasogenic edema)
-Posterior reversible encephalopathy syndrome (PRES)
Other Acute HTN Syndromes that cause ICH
-Eclampsia (pregnancy or puerperium, proteineuria, peripheral edema, seizures)
-Acute renal failure
-Drug related (cocaine, amphetamines, phenylpropanolamine, ephedrine)
-Hyperperfusion (= reperfusion) syndrome (after carotid endarterectomy or angioplasty/stenting
Acute-Subacute Management
-maintain systolic arterial p < 140
-prevent medical complications (in acute stroke unit)
-Obtain echocardiogram
-Most pts do NOT NEED SURGERY!
ICH indications for Surgery
Cerebellar Hemorrhage
-Depressed conscoiusness
-Brainstem compression
-> 3cm in size
-4th ventricle or quadrigeminal plate cistern obliteration

-Deteriorating consciousness
-Young patient
-Peripheral nondominant location
-To establish etiology
Cerebellar ICH
can't walk
Hydropcephalus ICH
decrease LOC
Brainstem compression
coma, abnormal eye, movements etc.
-external ventricular drain (temporary)
-Shunt (permanent)
-most common w/ thalamic hemorrhages
-may also occur w/ cerebellar or putaminal hemorrhages
ICH diagnosis
comb of focal (hemiparesis) & diffuse (decrease consciousness) brain signs

noncontrast CT (detects all ICH immediately)
ICH emergency care
-possible surgical resection (cerebellum or lobar) or ventriculostomy (hyrdocephalus)
-maintain systolic bp < 140
Subacute Care ICH
-prevent medical complications
Long term care / secondary prevention ICH
maintain BP < 120/80