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Cerebral hemorrhage

Cerebral hemorrhage. Etiology and pathogenesis. Hypertension and arteriosclerosis Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumor lenticulostriate arteries vertical to MCA

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Cerebral hemorrhage

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  1. Cerebral hemorrhage

  2. Etiology and pathogenesis • Hypertension and arteriosclerosis • Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumor • lenticulostriate arteries vertical to MCA • Microaneurysms → rupture

  3. Pathology • Site: basal ganglia (70%), brain lobe, brain stem, cerebellum • Lateral hemorrhage: the bleeding is confined lateral to the internal capsule (lenticular nucleus, external capsule) • Medial hemorrhage: thalamus • hematoma →edema →herniation hematoma →stroke capsule

  4. Clinical feature • Age: 50-70 • Male > female • Occur at physical exertion or excitement • Sudden onset of focal signs • Usually accompanied by headache and vomiting • May have consciousness disturbance

  5. Clinical feature 1. Putamen hemorrhage • contralateral hemiplegia, hemianesthesia, and hemianopia • Eyes are frequently deviated toward the side of the affected hemisphere • Aphasia if dominant hemisphere is affected

  6. Clinical feature 2. Thalamus hemorrhage • contralateral hemiplegia, hemianesthesia, and hemianopia • Deep sensation disturbance • Ocular signs • Disturbance of consciousness

  7. Clinical feature 3. Pontine hemorrhage • Mild: crossed paralysis • Severe (>5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours

  8. Clinical feature 4. Cerebellar hemorrhage • Occipital headache, intense vertigo and repeated vomiting, ataxia, nystagmus • Severe cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniation

  9. Clinical feature 5. Lobar hemorrhage • Seen in AVM, Moyamoya disease, • Headache, vomiting, neck stiffness • Seizure • Focal signs

  10. Investigation 1. CT • First choice • High density blood • Mass effect and edema • High density → isodensity → low density

  11. Investigation 2. MRI • Brain stem hemorrhage • <24h, not distinguishable with thrombosis 3. DSA • Young and with normal blood pressure 4. CSF • Bloody • Done only when the CT is not available and without increased ICP

  12. Diagnosis • Age >50, with hypertension • Sudden onset of headache, vomiting, focal sign • Occur at physical exertion or excitement • CT: high density blood

  13. Differential diagnosis • Coma: poisoning, hypoglycemia, hepatic or diabetic coma • Focal signs: cerebral infarction, brain tumor, subdural hematoma, SAH

  14. Treatment 1.Keep rest, monitoring, air way, good nursing 2. Keep electrolytes and fluid balance. 3. Reduce ICP: • 20% Mannitol 125-250ml, 3 to 4 times per day • Furosemide, albumin, dexamathasone

  15. Treatment 4. Control hypertension: <180/105mmHg in acute stage, ACEI, beta-blocker 5. Prevent complications: • Infection:antibiotics • gastric hemorrhage: Cimetidine, Losec • Venous thrombosis: heparin

  16. Treatment 6. Surgical therapy: • Putamen, lobar: >40-50 ml, deteriorating • Cerebellum: >15ml, diameter>3cm • Thalamus: obstructive hydrocephalus →ventricular drainage 7. Rehabilitation

  17. Subarachnoid hemorrhageSAH

  18. SAH • Cranial bone → dura mater → arachnoid → pia mater → brain lobe • Primary spontaneous SAH • Traumatic SAH • Secondary to cerebral hemorrhage

  19. Etiology • 1. Intracranial saccular aneurysm • 2. AVM (arteriovenous malformation) • 3. Hypertension and atherosclerosis • 4. Moyamoya disease • 5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleeding disease

  20. Pathology • Anterior cerebral and anterior communicating • Internal carotid • Middle cerebral • Basilar

  21. Clinical feature 1. Age of onset: • Saccular aneurysm: adult 30-60 • AVM: juvenile • Hypertension: more than 60 2. Prodromal symptoms • Warning leaks: headache, vomiting • Cranial nerve paralysis: oculomotor

  22. Clinical feature 3. Acute SAH • Sudden onset of severe headache: “explode, burst, the worst of my life” • Vomiting • Associated with physical exertion, excitement • Transient loss of consciousness or coma • Pain of neck, back, leg • Mental symptoms: apathy, lethargy, delirium

  23. Clinical feature 3. Acute SAH • Signs of meningeal irritation: neck stiffness, positive Kernig’s sign • Fundus examination: papilloedema, sub-hyaloid hemorrhage • Cranial nerve palsy

  24. Clinical feature 4. Delayed neurologic deficits • Rerupture: in first 4 weeks, again has severe headache, vomiting, unconsciousness, with poor outcome. Due to fibrinolysis • Cerebrovascular spasm: 4-15 days after initial SAH, → cerebral infarction →disturbance of consciousness and focal signs • Hydrocephalus: 2-3 weeks after SAH, → gait difficulty, incontinence, dementia

  25. Investigation 1. CT • Subarachnoid clot in 75% of cases

  26. Investigation 2. CSF • Uniformly blood-stained • Xanthochromia: 12 hours to 2-3 weeks • ICP ↑ 3. DSA: etiologic diagnosis, important to surgery 4. MRA, CTA

  27. Diagnosis • Sudden onset of severe headache, vomiting • Neck stiffness, positive Kernig’s sign • Uniformly blood stained CSF • CT shows subarachnoid clot

  28. Differential diagnosis • Cerebral hemorrhage • Meningitis • Tumor • Psychosis

  29. Treatment 1. General management • Absolute bed rest for 4-6 weeks • Prevent constipation, excitement • Sedatives and analgesics 2. Reduce ICP • Mannitol, Furosemide, albumin

  30. Treatment 3. Prevent rerupture • Antifibrinolytic drugs: EACA for 3 weeks 4. Prevent cerebrovascular spasm • Nimodipine, flunarizine 5. Lumbar puncture to replace CSF 6. Surgery: within 24-72 hours

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