Causes of ICH

• Spontaneous– Hypertensive– Amyloid angiopathy– Ruptures aneurysm

• Saccular• Mycotic

– Ruptured AVM– Bleeding into tumor– Bleeding disorders– Cocaine, amphetamine

• Traumatic

Hypertensive ICH

• spontaneous rupture of a small penetrating artery deep in the brain

• Sites– Basal ganglia (putamen, thalamus, and

adjacent deep white matter), – Cerebellum– Pons

ICH Clinical

• During wake and during stressed

• Abrupt onset with progression over 30-90min

Ganglionic Bleed

• Contralateral hemiparesis, hemisensory loss, and homonymous hemianopia

• Aphasia with dominant hemisphere

• Conjugate deviation of eyes downward or toward the side of the hematoma

• Obtundation, stupor, or coma

Cerebellar hemorrhage

• Vomiting and ataxia

• Skew deviation of eyes and small pupils

• Deviation of eyes toward the opposite side

• Obtundation, late-developing stupor, or coma

Pontine hemorrhage

• Abrupt onset of coma• Pinpoint, reactive pupils• Skew deviation of eyes and

gaze paresis• Decerebration or flaccidity• Ataxic respiration

Investigation

• CT scan• MRI• Angiography• CSF examination

Deep Cerebral hemorrhage

Treatment HICH

• Control BP

• Reduce intracranial pressure

• Surgical evacuation– Large lobar hematoma >5cm– Cerebellar hematoma >3cm– Large ganglionic bleed >5cm by

steritectic

Amyloid angiopathy

• Lobar hemorrhage in elderly

• Subcortical white matter

• Can have recurrent bleed

• Less severe focal neurologic deficit

• Onset over several minutes like infarct

• Investigation CT/MR

SAH : Facts

• usually after 3rd decade• annual rate 10/100,000• Should be same in India• Population of twin cities- 70,00,000• Expected cases; 700 cases per year• 10% die before reaching hospital• conservative treatment: 30 days mortality 50-

60%• risk of surgical mortality <5%

SAH Clinical picture

• Sudden severe headache, “bolt out of blue”• Sentinel; a milder variety which clears in a day or

two• Neck stiffness, photophobia• may have LOC• May have neurological deficit• Causes:

– aneurysmal 75-80%– AVM, tumor bleed, coagulopathies

SAH Investigation• CT scan:

– Small bleed may be missed in CT (10%)– After 7 days CT may be normal in 50% cases– CSF examined if CT normal it should not precede CT

• Lumber puncture:– opening pressure high– Definitive: RBC >100,000/cmm– Xanthochromia-develops in 1-2 days

• MRI– sensitive for bleed >10 days old– useless for acute investigation

Subarachnoid hemorrhage

• Bed rest Analgesic• Blood pressure control• Oral nimodipine 60mg q6hx21 days• Angiography for localization of bleedingIf aneurysm • Immediate surgical clipping for

– Grade 1-3 patient without contraindication– Grade 4-5 with intracerebral clot and deterioration