Hypertensive Intracerebral hematoma (Bleeding in the Brain)
Brain hemorrhage may occur within brain parenchyma or the surrounding brain coverings. Hemorrhage within the meninges or the associated potential spaces, including epidural hematoma, subdural hematoma, and subarachnoid hemorrhage. Brain parenchyma bleeding may be Intracerebral hemorrhage (ICH) or intraventricular bleeding.
Intracerebral hemorrhage accounts for 8-13% of all strokes. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially death.
What causes intracerebral hemorrhage( brain bleeding)?
- Arteriovenous malformation
- Aneurysmal rupture
- Cerebral amyloid angiopathy
- Intracranial neoplasm
- Hemorrhagic transformation of an ischemic infarct
- Cerebral venous thrombosis
- Sympathomimetic drug abuse
- Sickle cell disease
- Eclampsia or postpartum vasculopathy
- Neonatal intraventricular hemorrhage
What does hypertension do to brain blood vessels?
Chronic hypertension produces a small vessel vasculopathy characterized by lipohyalinosis, fibrinoid necrosis, and development of aneurysms, affecting main penetrating arteries which supply the most vital structures of the brain.(aneurysms of the small perforating arteries can be seen in the diagram)
Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the world.
Intracerebral hemorrhage has a 30-day mortality rate of 44% ( means 44 people out of 100 who have intracerebral bleeding will die with in one month). Pontine or other brainstem intracerebral hemorrhage has a mortality rate of 75% at 24 hours.
Intracerebral hemorrhage has a higher incidence among populations with a higher frequency of hypertension, including African Americans. A higher incidence of intracerebral hemorrhage has been noted in Chinese, Japanese, and other Asian populations, possibly due to environmental factors (eg, a diet rich in fish oils) and/or genetic factors.
Intracerebral hemorrhage has a slight male predominance.
Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade until age 80 years.
Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive (ie, minutes to hours) development of the following:
Alteration in level of consciousness (approximately 50%)
Nausea and vomiting (approximately 40-50%)
Headache (approximately 40%)
Seizures (approximately 6-7%)
Focal neurological deficits
CT scan is the imaging investigation of choice ( Example images given below)
Treatment and Management:
Admission to ICU, Control of BP, Seizure management, Brain pressure management, supporive care.
Recommendations (Americal college recommenations)
1. For most patients with ICH, the usefulness of surgery is uncertain
2. Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible.Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended .
3. For patients presenting with lobar clots >30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered .
4. The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational.
5. Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding.
Surgical options: Open craniotomy
Endoscopic removal of clot
Steriotactic aspiration of clot.