1. Brain haemorrhage

3. Etiology Non treated arterial hypertension Amyloid angiopathy Aneuryzms and AVM Head injury Complications of antikoagulant therapy Bleeding to brain infarct or tumor

4. Etiology 80% - typical hypertonic brain haemorrhage - thalamus and BG, cerebellum, midbrain 20% - other cause : atypical haemorrhage AVM Bleeding to brain tumor angiomas arterial aneurysms

5. Pathogenesis Bleeding to brain tissue compression of tissue destruction of tissue brain oedema posthemorrhagic pseudocyst

6. Clinical feature Very often very severe - focal signs, ICH, koma, epi.paroxysms, headache, vomitus, Prognosis depends on : cause, localisation, patient´s condition compensation

7. Dg. Brain CT Brain MRI In atypical haemorrhage - AG, DSA, MR- AG

8. Brain haemorrhage

9. Therapy Surgiical Conservative

10. SAH S ubarachnoid haemorrhage

11. S ubarachnoid haemorrhage Bleeding into the subarachnoid space surrounding the brain 5-10% of all strokes About 80% - rupture of an intracranial saccular aneurysm 20% - AVM, mycotic aneurysm Nonaneurysmal SAH

12. Etiology SAH 1. Saccular - „berry“- with nech and body the most often 2. Fusiform - without neck not so often 3. Dissecans

13. Etiology SAH - AVM

14. S ubarachnoid haemorrhage Sudden onset of excrutiating headache, sometimes accompanied by focal neurologic symptoms and signs or sudden coma

15. Risk factors SAH

16. The most often localisation  A. cerebri anterior, a. comunic.ant.  Bifurcation ICA and art. communicans post.  The origin of art. cerebri ant.  The first bifurcation of MCA  Bifurk. a.comm.post. and PCA  Bifurcation of BA  one aneurysm  or more aneurysms (30%)

17. The most often localisation

18. Clinical feature Incidence: 6-24 / 100 000, women, age 50.-60 Sudden onset of headache +- unconsciousness vomitus, defecation meningeal irritation +- focal neurological signs

19. Hunt-Hess classification (grading system) Grade 1 - headache, slight nuchal rigidity Grade 2 - cranial nerve palsy, severe headache, nuchal rigidity Grade 3 - mild focal deficit, lethargy, confusion Grade 4 - stupor, moderate-to-severe hemiparesis, early decerebrate rigidity Grade 5 - deep coma, decerebrate rigidity, moribund appearance

20. Dg. SAH Brain CTLumbar punction

21. Dg. SAH

22. Etiology SAH

23. Angiography 3D CT angiography

24. Etiology SAH - AVM

25. 3D CT angiography

26. Grading System of Fisher - CT 1. No subarachnoid blood detected 2. Diffuse vertical layers less than 1 mm 3. Localized clot and/or vertical layer more than 1 mm 4. Intracerebral or intraventricular clot with diffuse or no subarachnoid blood

27. Grading System of Fisher - CT Grade 1 - normal CT

28. Grading System of Fisher - CT

30. Therapy SAH Conservative - without origin of SAH rest in bed 14-21 days blood presure prevention of vasospasms - blockers of Ca chanels - Nimodipin - iv. pump prevention of caughing

31. Therapy SAH Clipping Therapy SAH STENT

32. Therapy SAH Clipping

33. Therapy SAH - clipping

34. Therapy SAH - Coiling

35. Therapy SAH - coilling

38. Coilling

39. Complications of SAH Increased ICP (+ brain herniation), sudden death compression of brain Affected brain perfussion - focal ischemia of brain Hydrocephalus - affected resorbtion of CSF Vazospasm (4.-14. day )- 40-70 % of patients Rebleeding - 25% (first 24 hours.) Complications of therapy

40. SAH complications Vazospasm Ca 2+ channel blockers Nimodipin i.v. pump Blood presure control

41. SAH complications Hydrocephalus Therapy – ventriculoperitoneal shunt