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