Cerebral hemorrhageCerebral hemorrhage

Etiology and pathogenesis Etiology and pathogenesis

Hypertension and arteriosclerosisAtherosclerosis, bleeding tendency

(hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumor

lenticulostriate arteries vertical to MCAMicroaneurysms → rupture

Pathology 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

Clinical featureClinical feature

Age: 50-70Male > femaleOccur at physical exertion or excitementSudden onset of focal signsUsually accompanied by headache and

vomiting May have consciousness disturbance

1. Putamen hemorrhagecontralateral hemiplegia, hemianesthesia,

and hemianopiaEyes are frequently deviated toward the

side of the affected hemisphereAphasia if dominant hemisphere is affected

Clinical featureClinical feature

2. Thalamus hemorrhage contralateral hemiplegia, hemianesthesia,

and hemianopiaDeep sensation disturbanceOcular signsDisturbance of consciousness

Clinical featureClinical feature

3. Pontine hemorrhageMild: crossed paralysisSevere (>5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours

Clinical featureClinical feature

4. Cerebellar hemorrhageOccipital headache, intense vertigo and

repeated vomiting, ataxia, nystagmusSevere cerebellar hemorrhage : coma,

compression of brain stem, tonsillar herniation

Clinical featureClinical feature

5. Lobar hemorrhageSeen in AVM, Moyamoya disease, Headache, vomiting, neck stiffnessSeizureFocal signs

Clinical featureClinical feature

Investigation Investigation

1. CT First choice High density blood Mass effect and edema High density →

isodensity → low density

2. MRIBrain stem hemorrhage<24h, not distinguishable with thrombosis3. DSAYoung and with normal blood pressure4. CSFBloodyDone only when the CT is not available and

without increased ICP

Investigation Investigation

Diagnosis Diagnosis

Age >50, with hypertensionSudden onset of headache, vomiting, focal

signOccur at physical exertion or excitementCT: high density blood

Differential diagnosisDifferential diagnosis

Coma: poisoning, hypoglycemia, hepatic or diabetic coma

Focal signs: cerebral infarction, brain tumor, subdural hematoma, SAH

Treatment 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

dayFurosemide, albumin, dexamathasone

4. Control hypertension: <180/105mmHg in acute stage, ACEI, beta-blocker

5. Prevent complications:Infection:antibioticsgastric hemorrhage: Cimetidine, LosecVenous thrombosis: heparin

Treatment Treatment

6. Surgical therapy: Putamen, lobar: >40-50 ml, deterioratingCerebellum: >15ml, diameter>3cmThalamus: obstructive hydrocephalus

→ventricular drainage

7. Rehabilitation

Treatment Treatment

Subarachnoid hemorrhageSubarachnoid hemorrhageSAHSAH

SAH SAH

Cranial bone → dura mater → arachnoid → pia mater → brain lobe

Primary spontaneous SAH

Traumatic SAHSecondary to cerebral

hemorrhage

Etiology Etiology

1. Intracranial saccular aneurysm 2. AVM (arteriovenous malformation) 3. Hypertension and atherosclerosis4. Moyamoya disease5. Mycotic aneurysm, tumor, polyarteritis

nodasa, bleeding disease

Pathology Pathology

Anterior cerebral and anterior communicating

Internal carotid Middle cerebralBasilar

Clinical featureClinical 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

3. Acute SAHSudden onset of severe headache: “explode,

burst, the worst of my life”VomitingAssociated with physical exertion, excitementTransient loss of consciousness or comaPain of neck, back, legMental symptoms: apathy, lethargy, delirium

Clinical featureClinical feature

3. Acute SAHSigns of meningeal irritation: neck stiffness,

positive Kernig’s signFundus examination: papilloedema,

sub-hyaloid hemorrhageCranial nerve palsy

Clinical featureClinical feature

4. Delayed neurologic deficitsRerupture: 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

Clinical featureClinical feature

InvestigationInvestigation

1. CTSubarachnoid clot in

75% of cases

2. CSFUniformly blood-stainedXanthochromia: 12 hours to 2-3 weeks ICP ↑

3. DSA: etiologic diagnosis, important to surgery

4. MRA, CTA

InvestigationInvestigation

Diagnosis Diagnosis

Sudden onset of severe headache, vomitingNeck stiffness, positive Kernig’s signUniformly blood stained CSFCT shows subarachnoid clot

Differential diagnosisDifferential diagnosis

Cerebral hemorrhageMeningitisTumorPsychosis

TreatmentTreatment

1. General management Absolute bed rest for 4-6 weeksPrevent constipation, excitementSedatives and analgesics

2. Reduce ICPMannitol, Furosemide, albumin

3. Prevent reruptureAntifibrinolytic drugs: EACA for 3 weeks

4. Prevent cerebrovascular spasmNimodipine, flunarizine

5. Lumbar puncture to replace CSF

6. Surgery: within 24-72 hours

TreatmentTreatment