Intracerebral hematoma

Dr Sriranganth HS
Dept. of general surgery, JJMMC
Introduction
• Intracranial haemorrhage classified:
• Intra axial
• Intra- parenchymal
• Intra- ventricular
• Extra-axial- EDH/ SDH/ SAH
Introduction
• Surgically relevant- traumatic intracerebral
haemorrhage/ TICH
• Post Traumatic brain injury is usually a CT finding.
• Often considered as high density areas on CT
Non surgical bleeds
• Sympathomimetic drug abuse
• Moyamoya disease (constricted blood vessels)
• Neonatal intraventricular haemorrhage
• Hypertension
• Arteriovenous malformation
• Aneurysm rupture
• Intracranial neoplasm
• Hemorrhagic transformation of an ischemic stroke
Etiopathogenesis of TICH
• Most commonly occur in areas where sudden
deceleration of the head causes the brain to impact
on bony prominences (e.g. temporal, frontal, and
occipital poles) in coup or contrecoup fashion.
• TICH often enlarge and/or coalesce with time as
seen on serial CTs.
• They also may appear in a delayed fashion.
• Usually produce much less mass effect than their
apparent size.
Clinical features of surgical
bleeds
• Based on site of contusion, focal neurological
deficits seen
• Rarely produce mass effect/ raised ICT
Clinical features of medical
bleeds
• Hypertension
• Fever
• Cardiac arrhythmias
• Nuchal rigidity
• Subhyaloid retinal hemorrhages
• Altered level of consciousness
• Anisocoria (unequal size of the eyes' pupils)
• Nystagmus (involuntary eye movement)
• Focal neurological deficits
Imaging
• High density areas on CT
• Surrounding low density
may represent associated
cerebral edema.
• CT scans months later
often show surprisingly
minimal or no
encephalomalacia.
Other modalities
• MRI
• Angiogram
• Carotid duplex- ultrasound to check how well blood
is flowing through the carotid arteries
• Transcranial Doppler- ultrasonography that
measure the velocity of blood flow through the
brain's blood vessels by measuring the echoes of
ultrasound waves moving transcranially
Emergency management
• Airway management
• Expansion of hemorrhage and elevated B.P:
• HTN increases bleed
• Controlling BP will cause ischemia to brain since brain in
adapted to high BP- Cerebral autoregulation
• CURRENT RECOMMENDATION : “ KEEP CEREBRAL
PERFUSION PRESSURE Between 50 to 70 mm Hg
IF ELEVATED ICP
• Tracheal intubation and acute hyperventilation
• Mannitol administration
• Elevation of head end of bed
• CSF drainage
• Control Blood pressure
Non-operative management
• With intensive monitoring and serial imaging
• Done in patients without neurologic compromise
and no significant mass effect on CT and controlled
ICP

• Consensus:
• Surgically evacuate if hematoma is >3cm
• 1-3cm is grey zone
• <1 cm- medically manage
Surgical management
Indications for surgical evacuation:
• progressive neurological deterioration
• medically refractory IC-HTN
• signs of mass effect on CT
• Volume > 50ml
• GCS = 6–8 with frontal or temporal TICH volume >
20cm3 with midline shift (MLS) ≥ 5mm
• compressed basal cisterns on CT
Thank you