Intra cranial hemorrhages agp

ICH

1. INTRA CRANIAL HEMORRHAGES A k s h a i G e orge P a u l

2. CLASSIFICATION EXTRA AXIAL Occurs within the skull but outside the brain tissue No edema surrounding the bleed INTRA AXIAL Occurs within the brain tissue A rim of edema surrounding the bleed

3. EXTRA AXIAL EPIDURAL SUB DURAL SUB ARACHNOID INTRA AXIAL INTRA PARENCHYMAL INTRA VENTRICULAR

4. EPIDURAL HEMORRHAGE B/w bone and outer layer of dura( endosteal) Causes- trauma (Motor vehicle accidents, fall, assault) Non traumatic causes- infection/abscess, coagulopathy, hemorrhagic tumors , AVMs Source- arterial ( Middle meningeal artery ) venous

5. > 95% is supratentorial Common sites- temporo- parietal region- “ Pterion ”

6. Presentation Associated with temporal bone # LUCID INTERVAL Headache Herniation- subfalcine , uncal CN VI involvement Midline shift

7. CT appearance Lenticular ( biconvex)

8. Why lenticular?? Fixed attachment of dura to cranial sutures Blood coming from a high pressure system

9. May cross the sutural lines in case of…. Skull # Sutural diastasis Vertex EDH

10. Venous EDH Due to tearing of venous sinuses within the dural space May cross the suture lines 3 types- i ) vertex ii) ant. Middle cranial fossa iii) occipital posterior fossa

11. Subdural hematoma B/w dura & arachnoid Caused by tearing of bridging cortical veins in the subdural space Not limited by sutural lines but by dural reflection Common sites- Upper & sides of frontal and parietal lobe

12. More common than EDH Causes- Direct cranial trauma acceleration forces ( whiplash injury) young & elderly people on anticoagulent meds

13. CT appearance ‘ Crescentic ’- concave surface facing away from the skull Extends beyond suture lines

14. Acute SDH

15. Sub acute SDH

16. Chronic subdural hygroma

17. Subarachnoid hemorrhage B/w arachnoid & pia Causes- head trauma saccular aneurysm AVMs ruptured mycotic aneurysm pituitary apoplexy cocaine use

18. Berry aneurysm Found in 2 % adults Most commonly seen at – Terminal internal carotid artery MCA bifurcation Top of basilar artery Can produce blood leaks- ‘ sentinel bleeds’ Can also compress adjacent structures Increased risk of re-bleeding

19. Common sites of Berry aneurysm

20. Clinical features of SAH ‘Thunder clap headache’ Transient loss of conciousness Vomiting & neck stiffness Focal neurologic symptoms eg - MCA bifurcation- hemiparesis, abulia , aphasia

21. SAH- types Supracellar cisterns with diffuse peripheral extension Perimesencephalic and basal cisterns Isolated cerebral convexity

22. CT appearance Hyper dense appearing sub arachnoid spaces- sulci area around circle of willis sylvian fissure Inter peduncular fossa

23. Intra cerebral hemorrhage Bleeding into the brain parenchyma Causes- hypertension embolism brain tumor coagulopathy drug abuse

24. Hypertensive ICH Spontaneous rupture small penetrating arteries of the brain Most common sites- basal ganglia(putamen) thalamus, cerebellum & pons Abruptly presents with focal symptoms that varies with site

25. Putamen Long standing poorly controlled HTN causes micro aneurysms- Charcot Bouchard aneurysm Adjacent internal caspule is affected- contralateral hemiparesis Stuporous or even comatose Ipsilateral dilated pupils Decerebrate rigidity

26. Thalamus Contralateral hemiplegia- IC involvement Sensory defecits Aphasia with preserved repition Homonymous visual field defects Ocular disturbances by extending to midbrain

27. Pons Due to lipohyalinosis of arteries 3Ps- pyrexia pin point pupils paralysis

28. Duret’s hemorrhage Small hemorrhages In pons and medulla Seen in people with brain herniation syndromes Due to rupture of perforating arteriess

29. Cerebellum Occipital headache, vomiting, ataxic gait Dizziness/vertigo Ipsilateral sixth nerve palsy Dysarthria , dysphagia Obstructive hydrocephalus

30. Lobar hemorrhage Affects a lobe of cerebrum Usually due to cerebral amyloid angiopathy

31. Jet hematoma Also called ‘Flame hemorrhages’ Intra parenchymal haemorrhage seen with ruptured Berry aneurysm Mostly located in the periphery of affected lobe Hematoma often points to the site of aneurysm

32. Intra ventricular hemorrhage Usually secondary to another hemorrhage Either rupture of intracerebral bleed or SAH More common in infants, esp in premature due to immaturity of blood vessels which are more susceptible to damage by HIE. Risk increases with extra- corporeal membrane oxygenation Obstructive hydrocephalus