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CNS HEMORRHAGES

CNS HEMORRHAGES. Rohit Mathew Roy MD-4 1046. Hemorrhage is loss of blood from the blood vessels This could be internally (blood leaks from a blood vessel inside the body) or externally (through nose, mouth, ear etc ) General Facts :

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CNS HEMORRHAGES

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  1. CNS HEMORRHAGES Rohit Mathew Roy MD-4 1046

  2. Hemorrhage is loss of blood from the blood vessels • This could be internally (blood leaks from a blood vessel inside the body) or externally (through nose, mouth, ear etc) • General Facts: - Hemorrhage is responsible for 35% of Pre-Hospital Deaths and about 40% of deaths in the first 24 hours - Arterial – Bright Red Blood Venous – Dark Red Capillary – Brick Red - General Hemorrhage classified on basis of severity

  3. Causes • Head Trauma • High Blood Pressure • Aneurysms • Blood Vessel Abnormalities • Blood or Bleeding Disorders • Brain Tumors • Liver Disease • Amyloid Angiopathy

  4. Symptoms • Severe Headache • Seizures • Weakness in an arm or leg • Nausea or Vomiting • Lethargy and Decreased Alertness • Difficulty performing basic functions (like swallowing, reading and writing, speech) • Hand tremors and loss of balance • Numbness and Tingling • Blurred Vision

  5. Classifications • Intra-Axial Hemorrhage – Bleeding within the Brain itself. This category includes: - Intraparenchymal Hemorrhage 1. Basal Ganglia Hemorrhage 2. Pontine Hemorrhage 3. Cerebellar Hemorrhage 4. Lobar Hemorrhage - Intraventricular Hemorrhage • Extra-Axial Hemorrhage – Occurs within the skull but outside the Brain tissue. There are 3 subtypes: - Epidural Hemorrhage - Subdural Hemorrhage - Subarachnoid Hemorrhage

  6. Intraparenchymal Hemorrhage • Bleeding within brain parenchyma • Subdivided on the basis of Location: - Basal Ganglia Hemorrhage - Pontine Hemorrhage Hypertensive - Cerebellar Hemorrhage - Lobar Hemorrhage - CerebralAmyloid Angiopathy Underlying Pathology for Hypertensive Intraparenchymal Hemorrhage is Charcot-Bouchard Aneurysm

  7. Pontine Hemorrhage (10%) Basal Ganglia Hemorrhage (80%) Cerebellar Hemorrhage (10%)

  8. Lobar Hemorrhage • Large, Located Superficially within the Cerebral Hemispheres • Commonly seen in Elderly Patients • Superficial location make them prone to extend into the subdural space (less commonly can also extend into the intraventricular system) • Underlying Pathology: Cerebral Amyloid Angiopathy: Amyloid Deposits seen on the walls of the vessels • Can also be associated with underlying lesions like Cerebral Arteriovenous Malformation, Cerebral or Venous Infarct and Underlying tumors. • Patients present with acute neurological deterioration (Decreased GCS). Headache may be present.

  9. Lobar Hemorrhage

  10. Intraventricular Hemorrhage • Denotes presence of blood within the ventricular system of the brain (can cause dev. of obstructive hydrocephalus) • Primary (blood in ventricle and little parenchymal blood) and Secondary (large extraventricular component within extension into ventricles) Types • Primary: Caused by Intraventricular Tumors, Vascular Malformations • Secondary: Intracerebral hemorrhage and Subarachnoid Hemorrhage • Clinical Presentation similar to subarachnoid hemorrhage. Severe Headache, Signs of Meningism (Photophobia, nausea, vomiting, neck stiffness), Loss of Consciousness, Seizures, Brainstem compression with Cardiorespiratory Compromise

  11. Intraventricular Hemorrhage

  12. Epidural Hemorrhage • Collection of blood between the inner surface of the skull and outer layer of dura mater. • Seen in people who have sustained head trauma (associated with skull fracture) • Source of Bleeding: Middle Meningeal Artery (most common) at the Temperoparietal Locus • CT Scan Appearance: Biconvex in Shape • Symptoms: Lucid interval followed by unconsciousness, Headache due to stripping of the dura from the skull, increase intracranial pressure, dilated pupil on side on injury, weakness of the extremities on the opposite side of lesion

  13. Epidural Hemorrhage

  14. Subdural Hemorrhage • Blood accumulating between the dura and arachnoid mater of the meninges around the brain • Young adults - Motor vehicle accidents, Elderly – Falls, Infants – Non-accidental injuries • Source of Bleeding: Stretching and tearing of Bridging Cortical Veins • CT Scan Appearance: Crescent shaped hematoma • Symptoms: Depressed Conscious State, Pupillary Abnormalities, Chronic cases in Elderly presents with Pseudo-Dementia

  15. Subdural Hemorrhage

  16. Subarachnoid Hemorrhage • Bleeding in the subarachnoid space (between the arachnoid membrane and pia mater) • More common in men less than 60 years of age • Major cause is rupture of a Cerebral Aneurysm, other causes include trauma (with cerebral contusion), can be spontaneous (berry aneurysm), Dural Arteriovenous Fistula, Cocaine use etc. • Symptoms: “Thunderclap” Headache, confusion and lowered level of consciousness, seizures, Terson Syndrome, Signs of Meningism (photophobia, nausea, vomiting and neck stiffness)

  17. Subarachnoid Hemorrhage

  18. Diagnosis • CT Scan • CT Angiography • CT Venogram • MRI • DSA (Digital Subtraction Catheter) Angiography

  19. Treatment • Treatment of Underlying Cause of Hemorrhage (eg. Aneurysm, AVM) • Treatment of Obstructive Hydrocephalus • Evacuation of the clot (via burr-hole or craniotomy) • Triple H therapy (Hemodilution, Hypertension, Hypervolemia) • ICP monitoring • Calcium Channel Blocker (nimodipine)

  20. Case Study • A 72-year-old womantrips on a toy truck left at the top of a flight of stairs by a grandchild and falls down the stairs. She does not lose consciousness. About 36 hours later, she develops a headache and confusion and is taken to the emergency department. On physical examination, she is conscious and has a scalp contusion on the occiput. What is the most likely location of an intracranial hemorrhage in this patient? A. Pontine B. Basal Ganglia C. Epidural D. Subdural

  21. References • http://www.nationaltraumainstitute.org/home/hemorrhage.html • http://www.webmd.com/brain/brain-hemorrhage-bleeding-causes-symptoms-treatments • http://radiopaedia.org/articles/intracranial_haemorrhage • http://emedicine.medscape.com/article/1137207-overview • http://interestingmedfacts.blogspot.com/2013/01/hemorrhage.html

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