1. INTRACRANIAL HEMORRHAGE By Dr Ambreen Assistant Professor Medicine

2. Case Presentation  A 55 yrs old man known Hpertensive from 3 yrs which is uncontrolled presented in emergency room with sudden onset of Headache, vomiting, got collapse wit loss of conciousness.

3. On Examination of Patient  Pulse 58/min Regular  BP 185/100  Respiratory rate 14/min  Temp 99.0 F  GCS 6/15Eye =1Motor=4 Verbal=1  Signs of Meningeal Irritation are Absent

4. PHYSICAL EXAMINATION  CVS : Normal 1 st and 2 nd hearts sounds with bradycardia, No raised JVP  CNS: GCS 6/15, SOMI –Ve, Pupil normal reactive to light, Fundus Showing Hypertensive changes i.e silver wiring, AV nipping and cotton wool spots and hemorrhages.  GIT: No visceromegaly, Bowel sounds are audible and normal.  Respirations: Vesicular breathing with no added sounds

5. What is the Diagnosis  Intra Caranial Hemorrhage  What is this?  It means blood got accumulated in brain  How?  There are multiple reasons for it….. Which are

6. Causes of Intracranial Hemorrhage  Hypertension  Arteriovenous malformations  Aneurysm  Neoplasm  Coagulopathy  Alcoholic liver disease  Hemophia  Warfrin  Toxic-cocaine  Amyloid angiopathy

7. Site of Intra Cranial Hemorrhages  Intra Parenchymal Basl gangila Cerebral Cortex Cerebellum Brainstem  Intraventricular Lateral ventricle 3 rd ventricle 4 th ventricle  Subarachnoid  Subdural  Extradural

8. Types of Intra Cranial Hemorrhgaes  Intra axial Intraparenchymal Intraventricular  Extra Axial Subdural Subarachnoid Epidural

9. Sites of Aneurysms Normal Circle of WillisSites of Aneurysms

10. Clinical Features of Intraparenchymal Hemorrhage  Clinical manifestations of intracerebral hemorrhage are determined by the size and location of hemorrhage,  Hypertension, fever, or cardiac arrhythmias  Nuchal rigidity  Subhyaloid retinal hemorrhages  Altered level of consciousness  Anisocoria

11. C/F

12. putamen  C/L hemiparesis  Arm & legs gradually weaken  Slurred speech  Eye deviate away from side of hemiparesis large – brain stem compression

13. Thalamic hemorrhage  c/l hemiparesis  Prominent sensory deficit  Dominant thalamus – aphasia  Non dominant – constructional apraxia  Ocular disturbance- extension into upper midbrain

14. Ocular disturbances  Deviation of eyes downward & inward  Unequal pupils with absence of light reactions  Ipsilateral horner’s syndrome  Paralysis of vertical gaze,nystagmus

15. Pontine hemorrhage  Deep coma with quadriplegia over few minutes  Pin point pupil reacting to light  Impaired reflex horizontal eye movements  Hyperpnoea,hyperhydrosis,hypertension are common

16. Cerebellar hemorrhage  Occipital headahe  Repeated vomiting  Ataxia  Dizziness and vertigo may be prominent

17.  Paresis of conjugate lateral gaze to the side of hemorrhage  Ipsilateral 6 th nerve palsy  Dysphagia,dysarthria

18. Cerebellar hmrg…  Later stage – BRAIN STEM COMPRESSION/HYDROCEPHALUS IMMEDIATE EVACUATION CAN BE LIFE SAVING !!

19. LOBAR HEMORRHAGE  occipital hemorrhage - hemianopia;  left temporal hemorrhage,-aphasia and delirium;  parietal hemorrhage - hemisensory loss;  frontal hemorrhage,-arm weakness  Focal headache and vomiting can occur

24. INTRACEREBRAL HEMORRHAGE MANAGEMENT

25. EMERGENCY MANAGEMENT  Airway managemant  Expansion of hemorrhage and elevated B.P ??  CURRENT RECOMMENDATION : “ KEEP CEREBRAL PERFUSION PRESSURE ABOVE 60 mm Hg “ ( MAP – ICP )

26. ELEVATED ICP –  Tracheal intubation and acute hyperventilation  Mannitol administration  Elevation of head end of bed  CSF drainage

27.  Blood pressure lowered with nonvasodilating IV drugs like nicardipine  Cerebellar hematoma > 3 cm – evacuation <1 cm- surgical removal usually unnecessary 1 cm – 3cm : carefully monitored

28.  Special attention to platelet count, PT, PTT to identify coagulopathy

29. Subarachnoid Hemorrhage Symptoms sudden onset severe Headache worst ever (Thunderclap) Signs BP elevation, Papilledema on Funduscopy Cranial nerve palsies Hemiparesis Neck Stiffness Investigation CT scan Brain Four vessel Angiogram Treatment Nimodipine Clipping or coiling of aneurysms `Control BP

30. Subdural Hemorrhage  History of falls, violence, motor vehicle accidents. blunt head trauma causing altered state of consciousness  GCS score is important as to determine the prognosis Cause Damage to bridging veins Investigation CT San Brain Treatment Surgical Decompression

31. Extradural Hemorrhage Clinical Features Headache, lucid interval, Nausea/vomiting, Seizures Focal neurologic deficits (eg, visual field cuts, aphasia, weakness, numbness) Cause Damage to Middle Meningeal Artery due to trauma Investigation CT Scan Brain Treatment  Burr holes and negative pressure drainage

32. THANKS