Intraparencyhmal / Intraventricular Hemorrhage

FACTS

Etiologies:
  • Hypertensive (most common) usually in basal ganglia (#1 location is putamen), thalamus, pons, cerebellum
  • Amyloid bleeds (lobar)
  • Arteriovenous malformation (anywhere but usually superficial/lobar)
  • Less common etiologies
    • neoplasms, most commonly metastatic melanona, choriocarcinoma, oligodendroglioma, any glioma
    • venous thrombosis (parasagittal)
    • blood dyscrasias/fat emboli (scattered petechial)

HPI

  • What was systolic blood pressure on arrival?
  • Medical history
    • AC/AP use
    • Known HTN? adherent to home meds?
    • Prior MI / stroke
    • smoker
    • amyloid angiopathy or bleeding diathesis in patient or family
    • any cancer history
    • dementia (check meds list too)
  • Social history
    • cocaine/amphetamine user
  • Review of systems
    • did the patient seize
    • Hydro symptoms:
      • drowsy / vomiting

PHYSICAL EXAM

Universal Neuro exam
  • mental status is most important because it will decide EVD placement. Are the patient’s eyes open spontaneously when you walk in the room or not?
  • Calculate GCS for the ICH score.
Lobe
Symptoms
Frontal lobe
Contralateral HA, hemiparesis in arm > leg/face
Parietal lobe
Contralateral sensory deficit and mild hemiparesis
Temporal (dominant) lobe
Poor auditory comprehension, good repetition
Occipital lobe
Ipsilateral eye pain, contralateral homonymous hemi
Putamen
Minority will have HA
Thalamus
- Contralateral hemisensory loss +/- hemiparesis when IC is involved
- if extension into upper brainstem: vertical gaze palsy, retraction nystagmus, skew deviation, loss of convergence, ptosis, miosis, anisocoria
 

IMAGING

CTH non-contrast
CTA H&N
MRI Brain w/o can show multiple amyloid bleeds not seen on dry CT
Locations of hypertensive bleeds
  • basal ganglia (putamen) (60%)
  • thalamus (20%)
  • pons (10%)
  • cerebellum (10%)
A/P
Admit to neuro-ICU (stroke if no EVD, NSGY if EVD)
Stroke consult
Reverse AP/AC
EVD pending mental status, no official scale but can basically use hunt hess, will be attending dependent
Systolic CAP 140
HOB > 30
Keppra usually only if seized (no prophylactic unless blood burden massive)
6 hour interval CTH or earlier based on clinical judgement (make sure dual energy if received contrast)
MRI Brain w/wo to rule out lesion, this is not a priority and should only be done once stability of bleed established on ≥ 6 hr dry CT and if patient is stable enough for transport / lying flat for 20-30 minutes
+/- DSA (can also be an AVM)

Amyloid Bleeds

Figure 1: Lobar Amyloid Bleed
Figure 1: Lobar Amyloid Bleed
Figure 2: Hypertensive bi-hemispheric IPH. This was such a profound bleed with origin of bleed difficult to determine however patient was SBP to 200s at time of presentation.
Figure 2: Hypertensive bi-hemispheric IPH. This was such a profound bleed with origin of bleed difficult to determine however patient was SBP to 200s at time of presentation.
Figure 3: Hypertensive RIGHT thalamic bleed with significant intraventricular extension, ventriculomegaly, and hydrocephalus.
Figure 3: Hypertensive RIGHT thalamic bleed with significant intraventricular extension, ventriculomegaly, and hydrocephalus.
Figure 4: Pontine hypertensive hemorrhage
Figure 4: Pontine hypertensive hemorrhage