Intracranial Hemorrhage

Intracranial Hemorrhage

ByDr Ambreen Assistant Professor Medicine

Case PresentationA 55 yrs old man known Hpertensive from 3 yrs which is uncontrolled presented in emergency room with sudden onset of Headache, vomiting , got collapse wit loss of conciousness.On Examination of PatientPulse 58/min RegularBP 185/100Respiratory rate 14/minTemp 99.0 FGCS 6/15Eye =1Motor=4Verbal=1Signs of Meningeal Irritation are AbsentPHYSICAL EXAMINATIONCVS : Normal 1st and 2nd hearts sounds with bradycardia, No raised JVPCNS: GCS 6/15, SOMI Ve, Pupil normal reactive to light, Fundus Showing Hypertensive changes i.e silver wiring, AV nipping and cotton wool spots and hemorrhages. GIT: No visceromegaly, Bowel sounds are audible and normal.Respirations: Vesicular breathing with no added soundsWhat is the DiagnosisIntra Caranial Hemorrhage

What is this?It means blood got accumulated in brain

How? There are multiple reasons for it.. Which are

Causes of Intracranial HemorrhageHypertensionArteriovenous malformationsAneurysmNeoplasmCoagulopathyAlcoholic liver diseaseHemophiaWarfrinToxic-cocaine Amyloid angiopathy

Site of Intra Cranial HemorrhagesIntra Parenchymal Basl gangilaCerebral CortexCerebellumBrainstem

IntraventricularLateral ventricle3rd ventricle4th ventricle

Subarachnoid

Subdural

Extradural

Types of Intra Cranial Hemorrhgaes

Intra axialIntraparenchymalIntraventricular

Extra AxialSubduralSubarachnoidEpiduralSites of Aneurysms

Normal Circle of WillisSites of Aneurysms

Clinical Features of Intraparenchymal HemorrhageClinical manifestations of intracerebral hemorrhage are determined by the size and location of hemorrhage,Hypertension, fever, or cardiac arrhythmiasNuchal rigiditySubhyaloid retinal hemorrhagesAltered level of consciousnessAnisocoria

C/F

putamenC/L hemiparesisArm & legs gradually weakenSlurred speechEye deviate away from side of hemiparesis

large brain stem compressionThalamic hemorrhagec/l hemiparesisProminent sensory deficitDominant thalamus aphasiaNon dominant constructional apraxia Ocular disturbance- extension into upper midbrain Ocular disturbancesDeviation of eyes downward & inwardUnequal pupils with absence of light reactionsIpsilateral horners syndromeParalysis of vertical gaze,nystagmusPontine hemorrhageDeep coma with quadriplegia over few minutesPin point pupil reacting to lightImpaired reflex horizontal eye movementsHyperpnoea,hyperhydrosis,hypertension are commonCerebellar hemorrhageOccipital headaheRepeated vomitingAtaxiaDizziness and vertigo may be prominentParesis of conjugate lateral gaze to the side of hemorrhageIpsilateral 6th nerve palsyDysphagia,dysarthriaCerebellar hmrgLater stage BRAIN STEM COMPRESSION/HYDROCEPHALUS IMMEDIATE EVACUATION CAN BE LIFE SAVING !!LOBAR HEMORRHAGEoccipital hemorrhage - hemianopia; left temporal hemorrhage,-aphasia and delirium; parietal hemorrhage - hemisensory loss; frontal hemorrhage,-arm weakness Focal headache and vomiting can occur

INTRACEREBRAL HEMORRHAGE MANAGEMENTEMERGENCY MANAGEMENTAirway managemantExpansion of hemorrhage and elevated B.P ?? CURRENT RECOMMENDATION : KEEP CEREBRAL PERFUSION PRESSURE ABOVE 60 mm Hg ( MAP ICP ) ELEVATED ICP Tracheal intubation and acute hyperventilationMannitol administration Elevation of head end of bedCSF drainage

Blood pressure lowered with nonvasodilating IV drugs like nicardipineCerebellar hematoma > 3 cm evacuation