Neurology
Summary
An intraparenchymal hemorrhage is any bleeding that occurs within brain tissue and can have a traumatic or spontaneous origin. It most commonly arises due to uncontrolled hypertension, particularly in elderly patients. This is because persistently high blood pressure can lead to small vessel vasculopathy and eventual rupture, which can typically be seen in the deep gray matter of the brain, such as the basal ganglia and the thalamus. Another significant cause of intraparenchymal hemorrhage is cerebral amyloid angiopathy (CAA), which is due to the deposition of beta amyloid proteins in small blood vessels, which can also lead to vessel rupture. Hemorrhages due to CAA are usually found in the subcortical and cortical areas of the brain.
Several other causes of intraparenchymal hemorrhage include hemorrhagic strokes or hemorrhagic transformations following an ischemic stroke, AV malformation and vasculitis, malignancy (particularly glioblastomas and brain metastases), anticoagulant use, cocaine use, and infections (particularly due to bacterial abscesses and the herpes simplex virus).
The clinical presentation of an intraparenchymal hemorrhage can range from headaches, vomiting, and confusion, to more severe symptoms including visual changes, aphasias, hemiplegia, seizure, and even coma. Cushing's triad, characterized by irregular breathing, bradycardia, and hypertension, results from elevated intracranial pressure (ICP) and can herald an impending herniation. When an intraparenchymal hemorrhage is suspected, a head CT without contrast should be ordered, and a CT angiogram might be required to assess for medium or large vessel hemorrhage. Management mainly involves strict control of blood pressure, anticoagulant reversal (if applicable), neurosurgical consultation for ICP management, potential decompressive craniotomy, and close observation with repeat neuro exams and serial CT imaging.
Lesson Outline
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FAQs
Uncontrolled hypertension is the most common spontaneous cause of an intraparenchymal hemorrhage. Other causes can be cerebral amyloid angiopathy (CAA), where there is a deposition of beta-amyloid proteins in small to medium blood vessels leading to vessel rupture, along with anticoagulant use, malignancy (such as glioblastoma or metastatic disease), cocaine use, and various bacterial and viral infections (including herpes simplex virus and bacterial abscesses).
The spectrum of neurological deficits arising from an intraparenchymal hemorrhage is dependent on the location and severity of the bleed. Symptoms can include headaches, confusion, seizures, varying degrees of aphasias, hemiplegia, and even coma. CushingÕs triad, which includes irregular breathing, bradycardia, and hypertension, is a sign of elevated intracranial pressure (ICP) that can result from an intraparenchymal hemorrhage.
The first and most appropriate test to diagnose an intraparenchymal hemorrhage is a head CT without contrast. For larger bleeds, a CT angiography is recommended. These imaging tests help in precisely locating the bleed and assessing its extent.
The management of an intraparenchymal hemorrhage involves controlling blood pressure, which is vital in reducing further bleeding and limiting damage. It may also necessitate a neurosurgical consultation for managing intracranial pressure (ICP), which might involve procedures like a decompressive craniotomy. Close observation with frequent neurological check-ups and repeat imaging is essential in the management plan to monitor the condition and adjust therapy accordingly.
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