Intracerebral Hemorrhage

Intracranial Hemorrhage
Intracranial Hemorrhage
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Subdural hematoma
• Epidural hematoma
Intracerebral Hemorrhage
• Trauma • Vascular malformations
• Hypertension • Amyloid angiopathy
• Tumor
• Primary
• Secondary
• Anticoagulation
• Thrombolytic therapy
• Vasculitis
• Substance abuse
Hypertensive I C H
Hypertensive I C H
• Risk Factors:
• Hypertension
• poor control, poor compliance with medication.
• Alcohol, tobacco, low serum cholesterol, aspirin.
• Miliary aneurysms (Charcot & Bouchard 1863, Cole & Yates)
• autopsy study 100 hypertensive +100 nonhypertensive
• Miliary aneurysms 46% vs 7% (85% of ICH subjects)
Hypertensive I C H
• Pathogenesis
• Hypertension
• Lipohyalinosis
• Penetrating arteries (50 – 200µm)
• Microaneurysms
• Secondary bleeding
Hypertensive I C H
Clinical Features
• Acute onset of Neurological deficits
• Evolution over minutes (occasionally few hours)
• Peak reached in minutes
• Rapid improvement very rare (vs. ischemia)
• Headache, Vomiting
• Altered sensorium
• Focal / generalised seizures
• Delayed worsening
• Extension of hemorrhage
• Edema
Hypertensive I C H
Putaminal Hematoma
Clinical Features contd.
• Contralateral
• Hemiparesis / hemiplegia
• Hemisensory loss in large bleed
• UMN facial palsy
• Language deficit (mild – moderate)*
• Eye signs
• Contralateral gaze palsy
• 3rd nerve palsy
• Altered sensorium in large bleed / IVH
Hypertensive I C H
Thalamic Hematoma
Clinical Features contd.
• Contralateral
• sensory loss
• Visual deficit
• UMN facial palsy
• Ataxia + weakness
• Language deficit (fluent)
• Eye signs (skew deviation, upgaze palsy)
• Altered sensorium
• Intraventricular bleed
• Large bleed
Hypertensive I C H
Lobar Hematoma
Clinical Features contd.
• Headache
• Contralateral deficits (depends on location of bleed)
• Seizures
• Signs of meningeal irritation
• Altered sensorium in large bleed
Hypertensive I C H
Pontine Hematoma
Clinical Features contd.
• Eyes
• Movements:
• Impaired / absent horizontal movements
• Preserved vertical movements
• Pupils: Pin point
• Hemiplegia / quadriplegia
• Facial weakness
• Sensory deficits
• Respiration
Hypertensive I C H
Cerebellar Hematoma
Clinical Features contd.
• Cerebellar Lobar hematoma
• Ipsilateral ataxia
• Hypotonia
• Eye signs
• Cerebellar Vermian Hematoma
• Bilateral ataxia
• Hypotonia
• Eye signs
• Large hematoma → Brainstem compression → absent corneal reflex, altered
sensorium, failure of breathing and circulation .
Hypertensive I C H
Investigations
• Cerebral Imaging
• CT scan
• MR imaging
• Angiography
• Blood
• Counts, smear, PT, APTT
• Biochemistry
• Sugar, RFT, LFT, Lipids
• ECG
Hypertensive I C H
Hypertensive I C H
Hypertensive I C H
Management
• Resuscitation
• Control hypertension
• IV Labetolol, Nicardepine,
• Other antihypertensive drugs
• Avoid vasodilators (NTG, nitroprusside)
• Anti-edema therapy
• Mannitol
• Hypertonic saline
• Frusemide
• Glycerol
• Steroids
• Factor VII
Hypertensive I C H
Management
• Anti-seizure drugs
• Positioning
• Nutrition
• Surgery
• Lobar bleed
• Cerebellar bleed
• Intraventricular bleed → Ventricular drainage.
• Minimally invasive surgery with fibrinolysis
• Role unclear for putamen / thalamus???
• Physical therapy.
Cerebral Venous
Thrombosis
Cerebral Venous Thrombosis
Anatomy
Cerebral Venous Thrombosis
Anatomy
Cerebral Venous Thrombosis
Anatomy
Cerebral Venous Thrombosis
Anatomy
Cerebral Venous Thrombosis
Risk factors
• Post – partum • Coagulation disorders
• Dehydration • Inflammations
• Hyper-homocystinemia • Trauma
• Alcohol • Tumor
• Tobacco • Blood
• Systemic
• Thrombophilia • Local
• Infections • Idiopathic
Cerebral Venous Thrombosis
Clinical features
Symptoms Signs
• Headache • Consciousness
• Vomiting • Papilledema
• Focal neurological deficit • Focal neurological deficit
• Hemiplegia • Hemiplegia
• Quadriplegia • Quadriplegia
• Alternating hemiplegia • Alternating hemiplegia
• Seizures • Eye signs (deep venous system)

• Altered sensorium • Neck stiffness

Cerebral Venous Thrombosis
Evaluation
• Blood
• Blood counts, smear, sickling
• PT - INR, APTT
• protein C, protein S, antithrombin III,…
• Bone marrow ?
• Biochemistry (RFT, LFT, homocystine)
• Serology (anticardiolipin antibodies, ANA,..)
• Radiology
• CT scan / MRI brain
• Angiography (conventional / MR angio / CT angio)
Cerebral Venous Thrombosis
Evaluation
Cerebral Venous Thrombosis
Evaluation
Cerebral Venous Thrombosis
Evaluation
Cerebral Venous Thrombosis
Evaluation
Cerebral Venous Thrombosis
Treatment
• Antiedema therapy
• Anticoagulation
• Treatment of underlying etiology
• Anti – epileptic medication *
• Thrombolytic therapy
• Mechanical Thrombectomy
• Nutrition, fluid balance
• Thank you…