1. INTRACRANIAL HEMORRHAGE

2. INTRACRANIAL HEMORRHAGES ARE
CLASSIFIED ON THE BASIS OF BOTH
• LOCATION
• UNDERLYING VASCULAR PATHOLOGY

3. DEPENDING ON LOCATION
INTRAAXIAL & EXTRA AXIAL

5. INTRA AXIAL HEMORRAGE- INTRA PARENCHYMAL
- INTRA VENTRICULAR
EXTRA AXIAL HEMORRHAGE
– EPIDURAL HEMORRHAGE
- SUBDURAL HEMORRHAGE
- SUBARACHNIOD HEMORRHAGE

6. INTRA PARENCHYMAL HEMORRHAGE
1. AETIOLOGY
A)
B)
C)
D)
E)
Hypertension
Trauma
Cerebral amyloid angiopathy
Advanced age
Cocaine and methamphetamine use

7. F) HEMORRHAGIC DISORDERS
G) NEOPLASMS
H) VASCULAR MALFORMATIONS

8. HYPERTENSIVE INTRAPARENCHYMAL HMRG
• SPONTANEOUS RUPTURE OF PENETRATING
ARTERIES DEEP IN THE BRAIN
• SITES
1. BASAL GANGLIA
2.THALAMUS
3.CEREBELLUM
4.PONS

9. • FOCAL DEFICIT EVOLVE OVER 20- 30
MINUTES
• DIMINISHING LEVEL OF CONSCIOUSNESS
• SIGNS OF RAISED ICP

10. C/F

11. putamen
•
•
•
•
C/L hemiparesis
Arm & legs gradually weaken
Slurred speech
Eye deviate away from side of hemiparesis
large – brain stem compression

12. Thalamic hemorrhage
•
•
•
•
•
c/l hemiparesis
Prominent sensory deficit
Dominant thalamus – aphasia
Non dominant – constructional apraxia
Ocular disturbance- extension into upper
midbrain

13. •
•
•
•
Ocular disturbances
Deviation of eyes downward & inward
Unequal pupils with absence of light reactions
Ipsilateral horner’s syndrome
Paralysis of vertical gaze,nystagmus

14. Pontine hemorrhage
• Deep coma with quadriplegia over few
minutes
• Pin point pupil reacting to light
• Impaired reflex horizontal eye movements
• Hyperpnoea,hyperhydrosis,hypertension are
common

15. Cerebellar hemorrhage
•
•
•
•
Occipital headahe
Repeated vomiting
Ataxia
Dizziness and vertigo may be prominent

16. • Paresis of conjugate lateral gaze to the side of
hemorrhage
• Ipsilateral 6th nerve palsy
• Dysphagia,dysarthria

17. Cerebellar hmrg…
• Later stage –
BRAIN STEM COMPRESSION/HYDROCEPHALUS
IMMEDIATE EVACUATION CAN BE LIFE SAVING !!

18. LOBAR HEMORRHAGE
• occipital hemorrhage - hemianopia;
• left temporal hemorrhage,-aphasia and
delirium;
• parietal hemorrhage - hemisensory loss;
• frontal hemorrhage,-arm weakness
• Focal headache and vomiting can occur

24. Cerebral amyloid angiopathy
• Elderly
• arteriolar degeneration and
amyloid deposition
• most common cause of lobar
hemorrhage in the elderly

26. • intracranial hemorrhages associated with
IV thrombolysis given for MI
• patients who present with multiple
hemorrhages (and infarcts) over several
months or years
• patients with "micro-bleeds" seen on brain
MRI sequences sensitive for hemosiderin

27. • pathologic demonstration of Congo red
staining of amyloid in cerebral vessels
• no specific therapy, although antiplatelet
and anticoagulating agents are typically
avoided.

28. • Cocaine and
methamphetamine are
frequent causes of stroke in
young (age <45 years)
patients

29. Cocaine
• enhances sympathetic activity
• acute, sometimes severe, hypertension,
• and this may lead to hemorrhage

30. • Intracranial hemorrhages
associated with anticoagulant
therapy can occur at any location
• evolve slowly, over 24–48 hours

31. • hematologic disorders
(leukemia, aplastic
anemia, thrombocytopenic
purpura)
• multiple ICHs.
• Skin and mucous membrane
bleeding offers a diagnostic clue

32. • Hemorrhage into a brain tumor may
be the first manifestation of neoplasm
I. Choriocarcinoma,
II. malignant melanoma,
III. renal cell carcinoma, and
IV. bronchogenic carcinoma
are among the most common metastatic
tumors associated with ICH

33. Other causes
• Head injury
• Hypertensive encephalopathy
• Sepsis

34. VASCULAR ANOMALIES

35. Arterio venous malformations

36. • BLEEDING
• HEADACHE
• SEIZURES

37. • MRI / Contrast CT / Angiogram

38. • Treatment: Surgery / stereotaxic radiation

39. Venous anomalies
• As a result of anomalous
cerebral, cerbellar / brainstem
venous drainage
• Are functional venous channels
• Surgery – risk of venous infarction
and hemorrhage

40. Capillary telangiectasia
• May be associated with
Hereditary hemorrhagic
telangiectasia / osler rendu
weber syndrome

41. • Typically : pons, deep cerebral white matter

45. Cavernous angioma
•
tuft of capillary
sinusoids within deep
hemispheric white
matter and brain stem
with normal intervening
neural structures

46. • < 1 cm diameter typically
• a/w venous anomalies
• Surgical resection reduce seizure risk and
bleeding risk

47. Dural ArterioVenous fistula

48. • connection b/w dural sinus and dural artery
• Pulsatile tinnitus / headache
• Surgical and endovascular techniques are
curative

49. INTRACEREBRAL HEMORRHAGE
MANAGEMENT

50. • PROGNOSIS & CLINICAL OUTCOME –
ICH SCORING SYSTEM

53. EMERGENCY MANAGEMENT
• Airway managemant
• Expansion of hemorrhage and elevated B.P ??
• CURRENT RECOMMENDATION :
“ KEEP CEREBRAL PERFUSION PRESSURE
ABOVE 60 mm Hg “ ( MAP – ICP )

54. •
•
•
•
ELEVATED ICP –
Tracheal intubation and acute
hyperventilation
Mannitol administration
Elevation of head end of bed
CSF drainage

55. • Blood pressure lowered with nonvasodilating
IV drugs like nicardipine
• Cerebellar hematoma
> 3 cm – evacuation
<1 cm- surgical removal usually unnecessary
1 cm – 3cm : carefully monitored

56. • Special attention to platelet count , PT, PTT
to identify coagulopathy

57. EXTRA AXIAL HEMORRHAGES
(EDH, SDH,SAH)

58. EDH

59. • Most common – tempero parietal region
• VESSELS :
1. Anterior & Posterior branches of
middle meningeal artery
2. Middle meningeal vein
‘’ lucid interval present ‘’

60. Kernohan’s notch effect
•
EDH – RAISED ICP
CONING OF SUPRATENTORIAL CONTENT THROUGH THE
TENTORIAL HIATUS
SHIFT OF MIDBRAIN TO THE OPPOSITE SIDE – INJURED BY
SHARP END OF TENTORIUM CEREBELLI

61. CORTICOSPINAL TRACT ON OPPOSITE SIDE
BEFORE DECUSSATION GETS INJURED
HEMIPARESIS AND PUPILLARY CHANGES ON
THE SIDE OF HEMATOMA

64. C/F
• h/o trauma/ fall…Transient loss of
consciousness..lucid interval…regain
consciousness
• Pupillary changes – hutchinsonian pupil
• Features of raised ICP

65. • X RAY & CT are diagnostic
• Immediate surgical intervention is life saving
• Complications – meningitis, post traumatic
amnesia,post traumatic epilepsy

66. Subdural hematoma

67. •
•
•
•
•
Old age, h/o minor trauma
No lucid interval,severe primary brain damage
LOC immediately – progressive
2 varieties : acute , chronic
Chronic – 2 – 4 weeks
- chronic subdural hygroma

68. Treatment :
• Craniotomy and clot evacuation
• Antibiotics
• Anticonvulsants for 3 years
• D/D – ICSOL , Electrolyte imbalance

69. SAH
• Sponateousnly / trauma
Causes
:
ANEURYSM RUPTURE
Hypertensiom
AV malformation
Blood dyscrasias
anticoagulant therapy

71. C/F
•
•
•
•
Features of raised ICP
SIGNS OF MENINGEAL IRRITATION
CRANIAL NERVES- 3,4,6
Pressure effect on surrounding structures

72. management
• Medical – adequate rest
- analgesics and sedatives for headache
-antifibrinolytics prevent rebleeding
-dehydrating measures for brain
-LP to relieve severe headache
Surgery – aneurysm ( clipping of its neck ) /
excision of AV malformation
after 6-14 days

74. Questions????

75. THANK YOU