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. Clinical feature 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

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

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

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

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

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

11. Investigation 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

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 ml, 3 to 4 times per day
Furosemide, albumin, dexamathasone

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

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

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. Clinical feature 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

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

24. Clinical feature 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

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

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

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