Updated: 9/6/2020

Parenchymal Hemorrhage

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Snapshot
  • A 61-year-old man presents to the emergency department after his son found him somnolent at his home on the floor. The son is not sure how this event occurred. Medical history is significant for hypertension, Alzheimer dementia, and atrial fibrillation. He is currently taking lisinopril, metoprolol, donepezil, and wafarin. A CT head without contrast is performed and demonstrates a cerebellar bleed. The bed is elevated, he is given mannitol and intravenous vitamin K and fresh frozen plasma. Neurosurgery is consulted for emergent cerebellar decompression.
Introduction
  • Definition
    • bleeding within the brain parenchyma
  • Epidemiology
    • risk factors
      • hypertension (most common) 
      • cerebral amyloid angiopathy (second most common)
  • Pathogenesis
    • hypertension vasculopathy
      • chronic hypertension leads to blood vessel wall thickening, leading to blood vessel rupture
      • may also form Charcot-Bouchard aneurysms, leading to an intraparechymal bleed
      • results in a basal ganglia bleed (most commonly the putamen)
      • other locations
        • thalamus
        • cerebellum 
        • lobar
        • pons
    • amyloid angiopathy
      • beta-amyloid deposits in the vessel wall, leading to blood vessel wall thickening
      • results in a lobar bleed 
Presentation
  • Symptoms/physical examination
    • depends on location of the bleed
    • headache, nausea/vomiting, and impaired conciousness in large bleeds
      • lethargy
      • headache
      • obtundation
    • contralateral limb weakness in putamenal bleeds
    • contralateral sensory deficits in thalamic bleeds
Imaging
  • CT head without contrast
    • indication
      • initial imaging study in patients with changes in cognition and neurological deficits
    • findings
      • basal ganglia bleed seen in hypertensive vasculopathy 
      • lobar bleed seen in amyloid angiopathy 
Studies
  • Serum
    • coagulation studies (PTT and INR)
  • Studies
    • cardiopulmonary monitoring
    • intracranial pressure monitor in altered patients
    • electroencephalogram
Differential
  • Migraine headaches
    • differentiating factor
      • neurological deficits typically associated with a headache
  • Epidural hematoma
    • differentiating factor
      • convex hyperdensity that does not surpass the suture lines on head CT without contrast
Treatment
  • Medical
    • mannitol or hypertonic saline
      • indication
        • effectively decreased intracranial pressure
    • antiepileptic drugs
      • indication
        • used to treat seizures
    • reversal of anticoagulation
      • indication
        • used in patients who are on anticoagulation (e.g., warfarin)
      • medications
        • vitamin K and fresh frozen plasma
          • used to reverse warfarin
        • protamine sulfate
          • used to reverse heparin
  • Operative
    • cerebellar decompression
      • indication
        • in patients with a cerebellar hemorrhage
          • the cerebellum is located in a tight compartment, placing the patient at risk for cerebral herniation and death
    • open craniotomy
      • indication
        • in patients with a supratentorial hemorrhage
Complications
  • Cerebral herniation
  • Seizures
  • Intraventricular bleeding
 

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(M2.NE.17.4867) A 67-year-old man presents to the emergency department for a headache. The patient states his symptoms started thirty minutes ago. He states he experienced a sudden and severe headache while painting his house, causing him to fall of the ladder and hit his head. He has also experienced two episodes of vomiting and difficulty walking since the fall. The patient has a past medical history of hypertension, obesity, and atrial fibrillation. His current medications include lisinopril, rivaroxaban, atorvastatin, and metformin. His temperature is 99.5°F (37.5°C), blood pressure is 150/105 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient localizes his headache to the back of his head. Cardiac exam reveals a normal rate and rhythm. Pulmonary exam reveals minor bibasilar crackles. Neurological exam is notable for minor weakness of the muscles of facial expression. Examination of cranial nerve three reveals a notable nystagmus. Heel to shin exam is abnormal bilaterally. The patient's gait is notably ataxic. A non-contrast CT scan of the head is currently pending. Which of the following is the most likely diagnosis? Tested Concept

QID: 109544
1

Cerebellar hemorrhage

54%

(27/50)

2

Pontine hemorrhage

10%

(5/50)

3

Thalamic hemorrhage

8%

(4/50)

4

Subarachnoid hemorrhage

24%

(12/50)

5

Subdural hematoma

4%

(2/50)

L 2 D

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