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Cerebral hemorrhage. Etiology and pathogenesis Hypertension and arteriosclerosis Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia,

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Presentation on theme: "Cerebral hemorrhage. Etiology and pathogenesis Hypertension and arteriosclerosis Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia,"— Presentation transcript:

1 Cerebral hemorrhage

2 Etiology and pathogenesis Hypertension and arteriosclerosis Atherosclerosis, bleeding tendency (hemophilia, leukemia, aplastic anemia, thrombocytopenia), congenital angiomatous malformation, arteritis, tumor lenticulostriate arteries vertical to MCA Microaneurysms → rupture

3 Pathology Site: basal ganglia (70%), brain lobe, brain stem, cerebellum Lateral hemorrhage: the bleeding is confined lateral to the internal capsule (lenticular nucleus, external capsule) Medial hemorrhage: thalamus hematoma →edema →herniation hematoma →stroke capsule

4 Clinical feature Age: 50-70 Male > female Occur at physical exertion or excitement Sudden onset of focal signs Usually accompanied by headache and vomiting May have consciousness disturbance

5 1. Putamen hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopia Eyes are frequently deviated toward the side of the affected hemisphere Aphasia if dominant hemisphere is affected Clinical feature

6 2. Thalamus hemorrhage contralateral hemiplegia, hemianesthesia, and hemianopia Deep sensation disturbance Ocular signs Disturbance of consciousness Clinical feature

7 3. Pontine hemorrhage Mild: crossed paralysis Severe (>5ml) coma pinpoint pupils hyperpyrexia tetraplegia die in 48 hours Clinical feature

8 4. Cerebellar hemorrhage Occipital headache, intense vertigo and repeated vomiting, ataxia, nystagmus Severe cerebellar hemorrhage : coma, compression of brain stem, tonsillar herniation Clinical feature

9 5. Lobar hemorrhage Seen in AVM, Moyamoya disease, Headache, vomiting, neck stiffness Seizure Focal signs Clinical feature

10 Investigation 1. CT First choice High density blood Mass effect and edema High density → isodensity → low density

11 2. MRI Brain stem hemorrhage <24h, not distinguishable with thrombosis 3. DSA Young and with normal blood pressure 4. CSF Bloody Done only when the CT is not available and without increased ICP Investigation

12 Diagnosis Age >50, with hypertension Sudden onset of headache, vomiting, focal sign Occur at physical exertion or excitement CT: high density blood

13 Differential diagnosis Coma: poisoning, hypoglycemia, hepatic or diabetic coma Focal signs: cerebral infarction, brain tumor, subdural hematoma, SAH

14 Treatment 1.Keep rest, monitoring, air way, good nursing 2. Keep electrolytes and fluid balance. 3. Reduce ICP: 20% Mannitol 125-250ml, 3 to 4 times per day Furosemide, albumin, dexamathasone

15 4. Control hypertension: <180/105mmHg in acute stage, ACEI, beta-blocker 5. Prevent complications: Infection:antibiotics gastric hemorrhage: Cimetidine, Losec Venous thrombosis: heparin Treatment

16 6. Surgical therapy: Putamen, lobar: >40-50 ml, deteriorating Cerebellum: >15ml, diameter>3cm Thalamus: obstructive hydrocephalus →ventricular drainage 7. Rehabilitation Treatment

17 Subarachnoid hemorrhage SAH

18 SAH Cranial bone → dura mater → arachnoid → pia mater → brain lobe Primary spontaneous SAH Traumatic SAH Secondary to cerebral hemorrhage

19 Etiology 1. Intracranial saccular aneurysm 2. AVM (arteriovenous malformation) 3. Hypertension and atherosclerosis 4. Moyamoya disease 5. Mycotic aneurysm, tumor, polyarteritis nodasa, bleeding disease

20 Pathology Anterior cerebral and anterior communicating Internal carotid Middle cerebral Basilar

21 Clinical feature 1. Age of onset: Saccular aneurysm: adult 30-60 AVM: juvenile Hypertension: more than 60 2. Prodromal symptoms Warning leaks: headache, vomiting Cranial nerve paralysis: oculomotor

22 3. Acute SAH Sudden onset of severe headache: “explode, burst, the worst of my life” Vomiting Associated with physical exertion, excitement Transient loss of consciousness or coma Pain of neck, back, leg Mental symptoms: apathy, lethargy, delirium Clinical feature

23 3. Acute SAH Signs of meningeal irritation: neck stiffness, positive Kernig’s sign Fundus examination: papilloedema, sub-hyaloid hemorrhage Cranial nerve palsy Clinical feature

24 4. Delayed neurologic deficits Rerupture: in first 4 weeks, again has severe headache, vomiting, unconsciousness, with poor outcome. Due to fibrinolysis Cerebrovascular spasm: 4-15 days after initial SAH, → cerebral infarction →disturbance of consciousness and focal signs Hydrocephalus: 2-3 weeks after SAH, → gait difficulty, incontinence, dementia Clinical feature

25 Investigation 1. CT Subarachnoid clot in 75% of cases

26 2. CSF Uniformly blood-stained Xanthochromia: 12 hours to 2-3 weeks ICP ↑ 3. DSA: etiologic diagnosis, important to surgery 4. MRA, CTA Investigation

27 Diagnosis Sudden onset of severe headache, vomiting Neck stiffness, positive Kernig’s sign Uniformly blood stained CSF CT shows subarachnoid clot

28 Differential diagnosis Cerebral hemorrhage Meningitis Tumor Psychosis

29 Treatment 1. General management Absolute bed rest for 4-6 weeks Prevent constipation, excitement Sedatives and analgesics 2. Reduce ICP Mannitol, Furosemide, albumin

30 3. Prevent rerupture Antifibrinolytic drugs: EACA for 3 weeks 4. Prevent cerebrovascular spasm Nimodipine, flunarizine 5. Lumbar puncture to replace CSF 6. Surgery: within 24-72 hours Treatment

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