00:01
So let's talk a little bit more
about intraparenchymal hemorrhage
and start with the definition.
00:06
Intraparenchymal hemorrhages
refer to a spontaneous
or traumatic bleed into
the brain parenchyma.
00:12
This is the second most common cause of
hemorrhagic cerebrovascular accidents
and also common complication
of traumatic brain injury.
00:21
When we think about hemorrhagic strokes,
there's subarachnoid hemorrhage,
and intraparenchymal hemorrhage.
00:26
So this is a type of
hemorrhagic stroke.
00:30
When we think about what's
happening in the brain,
this schematic again
can be helpful.
00:34
We're starting at the surface of the
brain outside the brain in the skull
and moving down
to the parenchyma.
00:39
And here we're looking at hemorrhages
that occur in the brain itself.
00:42
These patients present with
focal neurologic deficits,
small hemorrhages that may not
be associated with mass effect
and midline shift
and increased ICP,
and larger hemorrhages may be
associated with mass effect,
midline shift and increased ICP.
00:57
The location of that
hemorrhage in the brain
is going to determine the types of
symptoms that patients present with.
01:04
In terms of etiologies,
there are a number of different causes
of intraparenchymal hemorrhages.
01:09
Hypertensive hemorrhages occur in
the deep subcortical structures.
01:13
Vascular malformations like AVMs or
cavernous angiomas or dural AV fistulas.
01:19
Brain tumors both primary
and metastatic brain tumors.
01:23
Cerebral amyloid angiopathy,
hemorrhagic transformation
of an acute stroke
often at that 3-5 or
up to 7-day period
after an ischemic stroke
when the vessels are friable.
01:33
Trauma and other causes.
01:36
Sometimes infection and
CNS structures can do it
particularly if there's a shower of
infectious endocarditis, infectious emboli,
there can be an increased risk of
hemorrhage in the setting of an infection.
01:49
In terms of diagnosis,
again, non-contrast head CT
is how we diagnose
these hemorrhages.
01:55
It should be performed emergently, we're
looking for the location of the hemorrhage.
01:59
We're stratifying surrounding edema
and looking at other underlying factors
that could point us into
a specific etiology.
02:08
To distinguish between ischemic
stroke and intracranial hemorrhage,
non-contrast head CT should be performed
emergently in patients presenting
with an acute rapid onset of
a focal neurologic deficit.
02:21
In patients where there's ICH
or intracranial hemorrhage,
we manage the hemorrhage.
02:25
In patients where
there's not ICH,
patient should be evaluated
for IV tPA thrombectomy
or for acute interventions
for a stroke.
02:34
Follow up imaging is important.
02:35
We need to stratify whether the
hematoma hemorrhage is expanding or not.
02:39
And so typically repeat
CT or MRI are appropriate.
02:43
We evaluate for neurologic
deterioration in the interval
and patients with neurologic
deterioration should undergo stat imaging
or rapid imaging in
between surveillance scans.
02:53
Confirmation that hematoma stabilization
is important and typically,
we will perform follow up imaging at
12 or 24 hours after the initial image.
03:02
And brain MRI with contrast is a modality
of choice to evaluate for underlying tumor,
CTA or MRA can be used to evaluate
for vascular abnormalities
and MRI can be used also to evaluate for
underlying cerebral amyloid angiopathy
to figure out what the
cause is for the hemorrhage.
03:19
In the setting of trauma
MRI may not be needed,
as the result as the clinical
presentation of a traumatic event
followed by an intraparenchymal hemorrhage
may satisfy a definitive diagnosis.
03:31
In terms of management, timely
assessment in the ICU or in the hospital
is necessary for patients with
intraparenchymal hemorrhages.
03:40
The goal is to monitor
intracranial pressure,
follow their neurologic exam
monitor for hematoma expansion
correct electrolyte
abnormalities and coagulopathies.
03:50
Seizures can occur from
intraparenchymal hemorrhages
particularly those that are out
in the lobes or lobar hemorrhages
near the cortical surface and
should be managed and evaluated.
04:00
Surgical management could include
evacuation of the hematoma
or decompressive craniectomy.
04:05
But we really defer surgical
management only for those patients
who have significant
neurologic deterioration.
04:11
The hemorrhage and an
intraparenchymal hemorrhage
is in between normal
neural structures.
04:15
Ultimately, that hematoma will
resolve and go down over time
and the underlying brain
may largely be spared.
04:23
Neurons that have been
significantly compressed or damaged
as a result of the blood may result
in long term neurologic deficits.
04:30
But it's really dramatic
the types of improvement
and recovery we can
see in these patients.
04:34
And so surgical decompression,
evacuation or craniectomy
are reserved for patients who
have significant deterioration
despite conservative management.