Cerebral hemorrhage

Etiology and pathogenesis Hypertension and arteriosclerosis Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumor lenticulostriate arteries vertical to MCA Microaneurysms → rupture

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 feature Age: 50-70 Male > female Occur at physical exertion or excitement Sudden onset of focal signs Usually accompanied by headache and vomiting May have consciousness disturbance

Clinical feature 1. Putamen hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopia Eyes are frequently deviated toward the side of the affected hemisphere Aphasia if dominant hemisphere is affected

Clinical feature 2. Thalamus hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopia Deep sensation disturbance Ocular signs Disturbance of consciousness

Clinical feature 3. Pontine hemorrhage Mild: crossed paralysis Severe (>5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours

Clinical feature 4. Cerebellar hemorrhage Occipital headache, intense vertigo and repeated vomiting, ataxia, nystagmus Severe cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniation

Clinical feature 5. Lobar hemorrhage Seen in AVM, Moyamoya disease, Headache, vomiting, neck stiffness Seizure Focal signs

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

Investigation 2. MRI Brain stem hemorrhage <24h, not distinguishable with thrombosis 3. DSA Young and with normal blood pressure 4. CSF Bloody Done only when the CT is not available and without increased ICP

Diagnosis Age >50, with hypertension Sudden onset of headache, vomiting, focal sign Occur at physical exertion or excitement CT: high density blood

Differential diagnosis Coma: poisoning, hypoglycemia, hepatic or diabetic coma Focal signs: cerebral infarction, brain tumor, subdural hematoma, SAH

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 day Furosemide, albumin, dexamathasone

Treatment 4. Control hypertension: <180/105mmHg in acute stage, ACEI, beta-blocker 5. Prevent complications: Infection:antibiotics gastric hemorrhage: Cimetidine, Losec Venous thrombosis: heparin

Treatment 6. Surgical therapy: Putamen, lobar: >40-50 ml, deteriorating Cerebellum: >15ml, diameter>3cm Thalamus: obstructive hydrocephalus →ventricular drainage 7. Rehabilitation

Subarachnoid hemorrhage SAH

SAH Cranial bone → dura mater → arachnoid → pia mater → brain lobe Primary spontaneous SAH Traumatic SAH Secondary to cerebral hemorrhage

Etiology 1. Intracranial saccular aneurysm 2. AVM (arteriovenous malformation) 3. Hypertension and atherosclerosis 4. Moyamoya disease 5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleeding disease

Pathology Anterior cerebral and anterior communicating Internal carotid Middle cerebral Basilar

Clinical 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

Clinical feature 3. Acute SAH Sudden onset of severe headache: “explode, burst, the worst of my life” Vomiting Associated with physical exertion, excitement Transient loss of consciousness or coma Pain of neck, back, leg Mental symptoms: apathy, lethargy, delirium

Clinical feature 3. Acute SAH Signs of meningeal irritation: neck stiffness, positive Kernig’s sign Fundus examination: papilloedema, sub-hyaloid hemorrhage Cranial nerve palsy

Clinical feature 4. Delayed neurologic deficits Rerupture: 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

Investigation 1. CT Subarachnoid clot in 75% of cases

Investigation 2. CSF Uniformly blood-stained Xanthochromia: 12 hours to 2-3 weeks ICP ↑ 3. DSA: etiologic diagnosis, important to surgery 4. MRA, CTA

Diagnosis Sudden onset of severe headache, vomiting Neck stiffness, positive Kernig’s sign Uniformly blood stained CSF CT shows subarachnoid clot

Differential diagnosis Cerebral hemorrhage Meningitis Tumor Psychosis

Treatment 1. General management Absolute bed rest for 4-6 weeks Prevent constipation, excitement Sedatives and analgesics 2. Reduce ICP Mannitol, Furosemide, albumin

Treatment 3. Prevent rerupture Antifibrinolytic drugs: EACA for 3 weeks 4. Prevent cerebrovascular spasm Nimodipine, flunarizine 5. Lumbar puncture to replace CSF 6. Surgery: within 24-72 hours