Pathology Intracranial Hemorrhages Basic Science.pptx

Important points in Intracranial Hemorrhages for Basic Science Pathology.
Contains basic description, microscopy, treatments and complications. Sources mentioned in the last slide.

1. 7th November, 2023 Group “D” Department of Pathology Intracranial Hemorrhage

2. Contents Classification Epidural Haemorrhage Subdural Haemorrhage Subarachnoid Haemorrhage Intraparenchymal Haemorrhage Pathogenesis Morphology Clinical Features Complication Management Sources

3. Haemorrhages occurring within the cranial cavity either in the parenchyma or in the surrounding meninges is considered “Intracranial Haemorrhage ”

4. Classification Hemorrhages can be classified etiologically as traumatic and non traumatic Traumatic Haemorrhages Epidural haemorrhage Subdural haemorrhage Non-Traumatic Hemorrhages Subarachnoid hemorrhage Intrapaenchymal haemorrhage

5. Classification Hemorrhages can be classified etiologically as traumatic and non traumatic Traumatic Haemorrhages Epidural haemorrhage Subdural haemorrhage Non-Traumatic Hemorrhages Subarachnoid hemorrhage Intrapaenchymal haemorrhage

6. Epidural Haemorrhage Also called Epidural Hematoma Most commonly affected site: Temporal area Due to rupture of Middle Meningeal Artery Caused by: Road T raffic A ccidents Fall Biconvex white/ Lenticular appearance on CT Scan.

7. Epidural Haemorrhage Also called Epidural Hematoma Most commonly affected site: Temporal area Due to rupture of Middle Meningeal Artery Caused by: R oad T raffic A ccident Fall Biconvex white/ Lenticular appearance on CT Scan.

8. Subdural Hemorrhage Also called Subdural hematoma Site: Top and sides of frontal and parietal bones Due to rupture of bridging veins between brain and superior sagittal sinus. Causes R oad T raffic A ccidents Sports accidents Assaults Concavo convex (Crescent Moon) appearance.

9. Subdural Hemorrhage Also called Subdural hematoma Site: Top and sides of frontal and parietal bones Due to rupture of bridging veins between brain and superior sagittal sinus . Causes RTA Sports accidents Assaults Concavo convex (Crescent Moon) appearance.

10. Subarachnoid Haemorrhage Also called Subarachnoid hematoma Most common site is Circle of Willis Rupture of Congenital Berry Aneurysms results in subarachnoid hemorrhages Causes: Hematological disorders Vascular Malformations Tumors Syphilis Star Shaped Opacity seen in CT Scan

11. Subarachnoid Haemorrhage Also called Subarachnoid hematoma Most common site is Circle of Willis Rupture of Congenital Berry Aneurysms results in subarachnoid hemorrhages Causes: Hematological disorders Vascular Malformations Tumors Syphilis Star Shaped Opacity seen in CT Scan

12. Intraparenchymal Haemorrhage Also called Intracerebral haemorrhage /hematoma It is the hemorrhage within the brain parenchyma due to rupture of small intraparenchymal vessels Etiological factors: Hypertension Cerebral Amyloid Angiopathy Systemic Coagulatio n Disorders Neoplasms Vasculitis Aneurysms

13. Intraparenchymal Haemorrhage Also called Intracerebral haemorrhage /hematoma It is the hemorrhage within the brain parenchyma due to rupture of small intraparenchymal vessels Etiological factors: Hypertension (most common for deep parenchymal hemorrhage) Cerebral Amyloid Angiopathy (most common cause of lobar haemorrhage ) Systemic Coagulatio n Disorders Neoplasms Vasculitis Aneurysms

14. Intraparenchymal Haemorrhage Also called Intracerebral haemorrhage /hematoma It is the hemorrhage within the brain parenchyma due to rupture of small intraparenchymal vessels Etiological factors: Hypertension Cerebral Amyloid Angiopathy Systemic Coagulatio n Disorders Neoplasms Vasculitis Aneurysms

15. Intraparenchymal hemorrhage Pathogenesis Chronic Hypertension Formation of Microaneurysms and hyaline change in small perforating arteries Rupture of aneurysms Haemorrhage Cerebral Amyloid Angiopathy Accumulation of β-Peptide in small and medium sized cerebral blood vessels Weakening of Blood vessels Intracranial Atherosclerosis Due to no external lamina and impaired complement regulation, NF-kB etc Plaque instability and weakening of blood vessels Manifestations of Clinical Symptoms

16. Morphology Gross Acute hemorrhage are characterized by extravasation of blood with compression of adjacent parenchyma Borders of the lesions are sharply defined and have a rim of partially necrotic parenchyma Ipsilateral ventricles are distorted and compressed and may contain blood in their lumina. Old hemorrhage show areas of parenchymal cavitary destructions with a rim of brownish discolorations.

17. Morphology Microscopy Early lesions consist of a central core of clotted blood Surrounding brain tissues show anoxic neuronal and glial changes as well as edema Eventually edema resolves and lipid laden macrophages appear Proliferation of reactive astrocytes is seen at periphery of lesions

18. Area of Distortion Normal Parenchyma

19. H and E Congo Red Immune stain

20. Clinical Features Severe Headache Syncope Vomitting Convulsion Impairment of consciousness Cheyne-Stokes Breathing Spasticity

21. Complication Paralysis Raised Intracranial Pressure Seizures (may present as delayed complication) Hydrocephalus Mass Effect Venous Thromboembolism Cognitive and Functional Deficits Death

22. Management Prehospital setting: Airway, Breathing and Circulatory support Getting the patient to Emergency Department as soon as possible Gathering all important history regarding trauma, medical and drug history Hospital setting: Initially any and all coagulation abnormalities need to be corrected Includes treatment for known factor deficiencies and reversal of any anticoagulation agents patient may be taking In patients known to be taking Vit. K antagonists, correction using frozen plasma, Vitamin K, prothrombin complex as well as recombinant activated factor VIIa

23. Management In Hospital Setting contd … Reduction in Blood Pressure as ↑ BP results in hematoma expansion Systolic Blood pressure must be maintained at <140mmhg in patients whose normal Systolic BP is 150-220 mmgh Maintenance of normoglycemia In patients with severe mass effect, osmotic diuretics such as Mannitol or Hypertonic Saline may be administered To avoid Hydrocephalus in case of severe hemorrhage, an external ventricular drain can be inserted In Patients with intracerebral hemorrhage within posterior fossa, surgical evacuation of clot may be performed if the clot is > 3cm and is causing brainstem compression, decreased level of consciousness and/or hydrocephalus Recently, minimally invasive surgery with recombinant tissue plasminogen ( rtPA ) activator has been proposed, aimed at removal of clot by insertion of catheter and delivery of rtPA

24. Sources: Robbins and Cotran Pathological Basis of Disease - Kumar, Abas, Aster Textbook of Pathology - Harsh Mohan Davidson’s Principles and Practice of Medicine Intracerebral Hemorrhage - D. Rajashekar , J.W. Liang www.ncbi.nlm.nih.gov /books/NBK553103/ Cerebral Amyloid Angiopathy - J. Kuhn, T. Sharman www.ncbi.nlm.nih.gov /books/NBK556105/ Hemorrhagic Strokes caused by atherosclerosis of major intracranial arteries – C. Banerjee, M. Chimowitz d oi.org 10.1161%2FCIRCRESAHA.116.308441