Primary Intracerebral Haematoma/Intracerebral Haemorrhage
Bleeding into the brain parenchyma with formation of a focal hematoma. It affects males more than females and can occur at any age although incidence increases with increasing age.
Etiology and pathology
- Most haemorrhages in the brain parenchyma arise in the region of the small arteries that serve the basal ganglia, thalamus and brainstem.
- Most cases occur in patients with chronic hypertension which leads to lipohyalinosis and microaneurysms while cerebral amyloid angiopathy is more frequently seen in normotensive and elderly patients.
- An intracerebral haemorrhage produces direct destruction of tissue and compression of surrounding parenchyma.
- Deeply situated haemorrhage may rupture into the ventricular system or, rarely, rupture through to the surface of the brain.
Risk factors
- Increasing age
- Cigarette smoking
- Alcohol consumption
- Low serum cholesterol
- Amphetamines, Cocaine
- Exposure to extreme cold
- Vascular malformations
- Intracerebral tumors
- Trauma
- Bleeding diathesis – anticoagulants, antiplatalet drugs, thrombocytopenia, hemophylia, leukemia, etc.
- Haemorrhagic brain infarction, etc
Pathogenesis
- Rupture in a cerebral vessel with pathologically changed wall or aneurysms
- Diapedesis of blood through the walls of the small blood vessels into the brain
Clinical Features
- Sudden onset of headache, gradually increasing over seconds or minutes, localized at first in occipital area, and may later become generalized, spreading down the back of the neck.
- Often whilst physically active. The signs and symptoms depend on the location of haematoma.
- Patients with temporal or frontal lobe hematomas may present with sudden onset of seizures followed by some degree of contralateral hemiparesis.
- Seizures
- If ICH is causing significant damage, patients may also present with signs of brainstem compression including unilateral papillary dilatation, depressed level of consciousness, ataxic breathing, etc.
Neurological Examination
- Focal neurological deficit: determinated by the site and size of haematoma. If ICH becomes large, with raised intracranial pressure, then headache, vomiting and decreased level of consciousness occur.
- Depressed conscious level – in about 1/3 of patients, determined by site and size of haematoma
Diagnostic procedures
- An urgent CT: hyper-dense zones in the parenchyma with perifocal edema.
- MRI: Hypointense areas
- Cerebral angiography: Avascular zone in the hemorrhage area and displacement of the vascular network.
- CSF: ↑pressure, xanthochromia, pleocytosis, hyperproteinarchia up to 1g/l. Presence of oxyHb
Treatment
Conservative
- Patient may require immediate resuscitation
- Airway protection, adequate ventilation and blood pressure levels below 130 mmHg. Blood pressure control is often a problem in these patients.