Rohit Mathew RoyMD-41046

CNS HEMORRHAGES

Hemorrhage is loss of blood from the blood vessels

This could be internally (blood leaks from a blood vessel inside the body) or externally (through nose, mouth, ear etc)

General Facts: - Hemorrhage is responsible for 35% of Pre-Hospital Deaths and about 40% of deaths in the first 24 hours - Arterial – Bright Red Blood Venous – Dark Red Capillary – Brick Red - General Hemorrhage classified on basis of severity

Head TraumaHigh Blood PressureAneurysmsBlood Vessel AbnormalitiesBlood or Bleeding DisordersBrain TumorsLiver DiseaseAmyloid Angiopathy

Causes

Severe HeadacheSeizuresWeakness in an arm or legNausea or VomitingLethargy and Decreased AlertnessDifficulty performing basic functions (like

swallowing, reading and writing, speech)Hand tremors and loss of balanceNumbness and TinglingBlurred Vision

Symptoms

Intra-Axial Hemorrhage – Bleeding within the Brain itself. This category includes:

- Intraparenchymal Hemorrhage 1. Basal Ganglia Hemorrhage 2. Pontine Hemorrhage 3. Cerebellar Hemorrhage 4. Lobar Hemorrhage - Intraventricular HemorrhageExtra-Axial Hemorrhage – Occurs within the skull

but outside the Brain tissue. There are 3 subtypes: - Epidural Hemorrhage - Subdural Hemorrhage - Subarachnoid Hemorrhage

Classifications

Bleeding within brain parenchyma

Subdivided on the basis of Location: - Basal Ganglia Hemorrhage - Pontine Hemorrhage Hypertensive - Cerebellar Hemorrhage

- Lobar Hemorrhage - Cerebral Amyloid Angiopathy

Underlying Pathology for Hypertensive Intraparenchymal Hemorrhage is Charcot-Bouchard Aneurysm

Intraparenchymal Hemorrhage

BASAL GANGLIAHEMORRHAGE

PONTINE HEMORRHAGE

CEREBELLAR HEMORRHAGE

CAUSEPoorly Controlled Long Standing Hypertension (80%)

Poorly Controlled Hypertension (Poor Prognosis) (10%)

Poorly Controlled Hypertension but Can be secondary to underlying lesion (tumor or vascular ) (10%)

PATHOLOGYMicroaneurysms of Perforating Arteries (lenticulo-strait vessels), Atherosclerosis

Penetrating arteries from basilar artery extending to pons prone to rupture (Larger Paramedian Perforators)

Perforating Vessels

SYMPTOMS

Loss of consciousness, Headaches, Nausea, Vomiting, Seizures

Decreased Consciousness, Tetraparesis, Seizures, Cheyne-Stokes Respiration

Ataxia, Nystagmus, Impaired Consciousness, Obstructive Hydrocephalus

ADDITIONAL INFORMATION

Common location is the Putamen (contralateral hemiplegia, hemianesthesia and hemianopia)

Secondary causes involve tumor, vascular malformations, downward herniation and supratentorial surgery

Good Prognosis,Secondary cause involves tumor, supratentorial surgery

Basal Ganglia Hemorrhage (80%)

Pontine Hemorrhage (10%)

Cerebellar Hemorrhage (10%)

Large, Located Superficially within the Cerebral Hemispheres

Commonly seen in Elderly PatientsSuperficial location make them prone to extend into

the subdural space (less commonly can also extend into the intraventricular system)

Underlying Pathology: Cerebral Amyloid Angiopathy: Amyloid Deposits seen on the walls of the vessels

Can also be associated with underlying lesions like Cerebral Arteriovenous Malformation, Cerebral or Venous Infarct and Underlying tumors.

Patients present with acute neurological deterioration (Decreased GCS). Headache may be present.

Lobar Hemorrhage

Lobar Hemorrhage

Denotes presence of blood within the ventricular system of the brain (can cause dev. of obstructive hydrocephalus)

Primary (blood in ventricle and little parenchymal blood) and Secondary (large extraventricular component within extension into ventricles) Types

Primary: Caused by Intraventricular Tumors, Vascular Malformations

Secondary: Intracerebral hemorrhage and Subarachnoid Hemorrhage

Clinical Presentation similar to subarachnoid hemorrhage. Severe Headache, Signs of Meningism (Photophobia, nausea, vomiting, neck stiffness), Loss of Consciousness, Seizures, Brainstem compression with Cardiorespiratory Compromise

Intraventricular Hemorrhage

Intraventricular Hemorrhage

Collection of blood between the inner surface of the skull and outer layer of dura mater.

Seen in people who have sustained head trauma (associated with skull fracture)

Source of Bleeding: Middle Meningeal Artery (most common) at the Temperoparietal Locus

CT Scan Appearance: Biconvex in ShapeSymptoms: Lucid interval followed by

unconsciousness, Headache due to stripping of the dura from the skull, increase intracranial pressure, dilated pupil on side on injury, weakness of the extremities on the opposite side of lesion

Epidural Hemorrhage

Epidural Hemorrhage

Blood accumulating between the dura and arachnoid mater of the meninges around the brain

Young adults - Motor vehicle accidents, Elderly – Falls, Infants – Non-accidental injuries

Source of Bleeding: Stretching and tearing of Bridging Cortical Veins

CT Scan Appearance: Crescent shaped hematoma

Symptoms: Depressed Conscious State, Pupillary Abnormalities, Chronic cases in Elderly presents with Pseudo-Dementia

Subdural Hemorrhage

Subdural Hemorrhage

Bleeding in the subarachnoid space (between the arachnoid membrane and pia mater)

More common in men less than 60 years of ageMajor cause is rupture of a Cerebral Aneurysm,

other causes include trauma (with cerebral contusion), can be spontaneous (berry aneurysm), Dural Arteriovenous Fistula, Cocaine use etc.

Symptoms: “Thunderclap” Headache, confusion and lowered level of consciousness, seizures, Terson Syndrome, Signs of Meningism (photophobia, nausea, vomiting and neck stiffness)

Subarachnoid Hemorrhage

Subarachnoid Hemorrhage

CT Scan

CT Angiography

CT Venogram

MRI

DSA (Digital Subtraction Catheter) Angiography

Diagnosis

Treatment of Underlying Cause of Hemorrhage (eg. Aneurysm, AVM)

Treatment of Obstructive Hydrocephalus

Evacuation of the clot (via burr-hole or craniotomy)

Triple H therapy (Hemodilution, Hypertension, Hypervolemia)

ICP monitoring

Calcium Channel Blocker (nimodipine)

Treatment

A 72-year-old woman trips on a toy truck left at the top of a flight of stairs by a grandchild and falls down the stairs. She does not lose consciousness. About 36 hours later, she develops a headache and confusion and is taken to the emergency department. On physical examination, she is conscious and has a scalp contusion on the occiput. What is the most likely location of an intracranial hemorrhage in this patient?

A. PontineB. Basal GangliaC. Epidural D. Subdural

Case Study

http://www.nationaltraumainstitute.org/home/hemorrhage.html

http://www.webmd.com/brain/brain-hemorrhage-bleeding-causes-symptoms-treatments

http://radiopaedia.org/articles/intracranial_haemorrhage

http://emedicine.medscape.com/article/1137207-overview

http://interestingmedfacts.blogspot.com/2013/01/hemorrhage.html

References