Intraparenchymal hemorrhage

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Lobus frontalis, parietal, temporalis intraparenchymal hemorrhage
Classification and external resources

Multiple intraparenchymal hemorrhage
ICD-10I61.6
ICD-9431
MeSHD002543
 
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Lobus frontalis, parietal, temporalis intraparenchymal hemorrhage
Classification and external resources

Multiple intraparenchymal hemorrhage
ICD-10I61.6
ICD-9431
MeSHD002543

Intraparenchymal hemorrhage (IPH) is one extension of intracerebral hemorrhage (the other is intraventricular hemorrhage (IVH)) with bleeding within brain parenchyma.

Intraparenchymal hemorrhage accounts for approx. 8-13% of all strokes and results from a wide spectrum of disorders. It is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage, and therefore constitutes an immediate medical emergency. Intracerebral hemorrhages and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.

Contents

Pathophysiology

Nontraumatic intraparenchymal hemorrhage most commonly results from hypertensive damage to blood vessel walls e.g.: - hypertension - eclampsia - drug abuse, but it also may be due to autoregulatory dysfunction with excessive cerebral blood flow e.g.: - reperfusion injury - hemorrhagic transformation - cold exposure - rupture of an aneurysm or arteriovenous malformation (AVM) - arteriopathy (e.g. cerebral amyloid angiopathy, moyamoya) - altered hemostasis (e.g. thrombolysis, anticoagulation, bleeding diathesis) - hemorrhagic necrosis (e.g. tumor, infection) - venous outflow obstruction (e.g. cerebral venous sinus thrombosis). Nonpenetrating and penetrating cranial trauma can be also common causes of intracerebral hemorrhage.

Physical Symptoms

Clinical manifestations of intraparenchymal hemorrhage are determined by the size and location of hemorrhage, but may include the following:

Causes

Diagnosis

Computed tomography (CT scan): A CT scan may be normal if it is done soon after the onset of symptoms. A CT scan is the best test to look for bleeding in or around your brain. In some hospitals, a perfusion CT scan may be done to see where the blood is flowing and not flowing in your brain.

Magnetic resonance imaging (MRI scan): A special MRI technique (diffusion MRI) may show evidence of an ischemic stroke within minutes of symptom onset. In some hospitals, a perfusion MRI scan may be done to see where the blood is flowing and not flowing in your brain.

Angiogram: a test that looks at the blood vessels that feed the brain. An angiogram will show whether the blood vessel is blocked by a clot, the blood vessel is narrowed, or if there is an abnormality of a blood vessel known as an aneurysm.

Carotid duplex: A carotid duplex is an ultrasound study that assesses whether or not you have atherosclerosis (narrowing) of the carotid arteries. These arteries are the large blood vessels in your neck that feed your brain.

Transcranial Doppler (TCD): Transcranial Doppler is an ultrasound study that assesses whether or not you have atherosclerosis (narrowing) of the blood vessels inside of your brain. It can also be used to see if you have emboli (blood clots) in your blood vessels.

Treatment

Intracerebral hemorrhages is a severe condition requiring prompt medical attention. Treatment goals include lifesaving interventions, supportive measures, and control of symptoms. Treatment depends on the location, extent, and cause of the bleeding. Often, treatment can reverse the damage that has been done.

A craniotomy is sometimes done to remove blood, abnormal blood vessels, or a tumor. Medications may be used to reduce swelling, prevent seizures, lower blood pressure, and control pain.

Acute Intraparenchymal Hemorrhage

Clinical History: 81 year old diabetic male presents with a change in mental status.

Findings: Axial CT images through the brain demonstrate two areas of hyperdensity, one measuring approximately 2 x 1.5 cm and a second measuring approximately 3 x 4 cm. There is some surrounding edema with mass effect upon the left ventricle. In addition, there is extension into the ventricular system.

Diagnosis: Acute intraparenchymal hemorrhage.

Discussion: There are many causes for intraparenchymal hemorrhage. A common cause is secondary to hypertension. These most commonly occur within the basal ganglia, subcortical white matter, cerebellum, thalamus and pons. Hemorrhage into the posterior fossa with mass effect or extension into the ventricular system carries poor prognosis.

In younger patients, vascular malformations, specifically AVMs and cavernous angiomas are more common causes for hemorrhage. In addition, venous malformations are associated with hemorrhage.

In the elderly population, amyloid angiopathy is associated with cerebral infarcts as well as hemorrhage in superficial locations, rather than deep white matter or basal ganglia. These are usually described as "lobar". These bleedings are not associated with systemic amyloidosis.

Hemorrhagic neoplasms are more complex, heterogeneous bleeds often with associated edema. These hemorrhages are related to tumor necrosis, vascular invasion and neovascularity. Glioblastomas are the most common primary malignancies to hemorrhage while thyroid, renal cell carcinoma, melanoma, and lung cancer are the most common causes of hemorrhage from metastatic disease.

Other causes of intraparenchymal hemorrhage include hemorrhagic transformation of infarction which is usually in a classic vascular distribution and is seen in approximately 24 to 48 hours following the ischemic event. This hemorrhage rarely extends into the ventricular system.

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