Intracranial hemorrhage

2. Causes of ICH
•Spontaneous
–Hypertensive
–Amyloid angiopathy
–Ruptures aneurysm
•Saccular
•Mycotic
–Ruptured AVM
–Bleeding into tumor
–Bleeding disorders
–Cocaine, amphetamine
•Traumatic

3. Hypertensive ICH
•spontaneous rupture of a small
penetrating artery deep in the brain
•Sites
–Basal ganglia (putamen, thalamus, and
adjacent deep white matter),
–Cerebellum
–Pons

4. ICH Clinical
•During wake and during stressed
•Abrupt onset with progression over
30-90min

5. Ganglionic Bleed
•Contralateral hemiparesis, hemisensory
loss, and homonymous hemianopia
•Aphasia with dominant hemisphere
•Conjugate deviation of eyes downward
or toward the side of the hematoma
•Obtundation, stupor, or coma

6. Cerebellar hemorrhage
•Vomiting and ataxia
•Skew deviation of eyes and small pupils
•Deviation of eyes toward the opposite side
•Obtundation, late-developing stupor, or
coma

7. Pontine hemorrhage
•Abrupt onset of coma
•Pinpoint, reactive pupils
•Skew deviation of eyes and gaze
paresis
•Decerebration or flaccidity
•Ataxic respiration

8. Investigation
•CT scan
•MRI
•Angiography
•CSF examination

9. Deep Cerebral hemorrhage

10. Treatment HICH
•Control BP
•Reduce intracranial pressure
•Surgical evacuation
–Large lobar hematoma >5cm
–Cerebellar hematoma >3cm
–Large ganglionic bleed >5cm by
steritectic

11. Amyloid angiopathy
•Lobar hemorrhage in elderly
•Subcortical white matter
•Can have recurrent bleed
•Less severe focal neurologic deficit
•Onset over several minutes like infarct
•Investigation CT/MR

12. SAH : Facts
•usually after 3rd decade
•annual rate 10/100,000
•Should be same in India
•Population of twin cities- 70,00,000
•Expected cases; 700 cases per year
•10% die before reaching hospital
•conservative treatment: 30 days mortality
50-60%
•risk of surgical mortality <5%

13. SAH Clinical picture
•Sudden severe headache, “bolt out of blue”
•Sentinel; a milder variety which clears in a day or
two
•Neck stiffness, photophobia
•may have LOC
•May have neurological deficit
•Causes:
–aneurysmal 75-80%
–AVM, tumor bleed, coagulopathies

14. SAH Investigation
•CT scan:
–Small bleed may be missed in CT (10%)
–After 7 days CT may be normal in 50% cases
–CSF examined if CT normal it should not precede CT
•Lumber puncture:
–opening pressure high
–Definitive: RBC >100,000/cmm
–Xanthochromia-develops in 1-2 days
•MRI
–sensitive for bleed >10 days old
–useless for acute investigation

16. Subarachnoid hemorrhage
•Bed rest Analgesic
•Blood pressure control
•Oral nimodipine 60mg q6hx21 days
•Angiography for localization of bleeding
If aneurysm
•Immediate surgical clipping for
–Grade 1-3 patient without contraindication
–Grade 4-5 with intracerebral clot and deterioration