Intracerebral hemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain.

The sudden increase in pressure within the brain can cause damage to the brain cells surrounding the blood. If the amount of blood increases rapidly, the sudden buildup in pressure can lead to unconsciousness or death. 

Intracerebral hemorrhage usually occurs in selected parts of the brain, including the basal ganglia, cerebellum, brain stem, or cortex.

What causes it?

The most common cause of intracerebral hemorrhage is high blood pressure (hypertension). Since high blood pressure by itself often causes no symptoms, many people with intracranial hemorrhage are not aware that they have high blood pressure, or that it needs to be treated.

Less common causes of intracerebral hemorrhage include trauma, infections, tumors, blood clotting deficiencies, and abnormalities in blood vessels (such as arteriovenous malformations). View an interactive tutorial on arteriovenous malformations from the Toronto Brain Vascular Malformation Study Group.

Intracerebral Hemorrhage

When blood vessels within the brain become damaged, they are more likely to burst and cause a hemorrhage.

 

 

Pathological conditions associated with ICH:

{arteriovenous malformation, or intraparenchymal hemorrhage may also present with headache alone. }

ruptured saccular aneurysm

Hypertension

●Cerebral amyloid angiopathy

●Vascular malformations

●Hemorrhagic infarction (including venous sinus thrombosis)

●Septic embolism, mycotic aneurysm

●Brain tumor

●Bleeding disorders, liver disease, anticoagulants, thrombolytic therapy

●Central nervous system (CNS) infection (eg, herpes simplex encephalitis)

●Moyamoya

●Vasculitis

●Drugs (cocaine, amphetamines) [7]. Phenylpropanolamine in appetite suppressants, and possibly cold remedies, may be an independent risk factor for intracranial hemorrhage (including intracerebral hemorrhage and subarachnoid hemorrhage) in women [8,9]. Caffeine-containing medications have also been associated with ICH [10].

 

 

What is the cause

spontaneous intracerebral hemorrhage (bleeding within the brain parenchyma),

subarachnoid hemorrhage from aneurysm rupture,

and intracranial bleeding from cranial trauma

 

Patients with ICH whose systolic BP exceeded 180 mm Hg at presentation.

Aim for a systolic BP of ≈160 mm Hg

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Who gets it?

Intracerebral Hemorrhage - Coronal Edema

A ruptured blood vessel will leak blood into the brain, eventually causing the brain to compress due to the added amount of fluid.

Intracerebral hemorrhage occurs at all ages. The average age is lower than for ischemic stroke. Less common than ischemic strokes, hemorrhagic strokes make up about 12 percent of all strokes.

 

 

Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.

 

Large hemorrhages are fatal within a few days in about half of patients. In survivors, consciousness returns and neurologic deficits gradually diminish to various degrees as the extravasated blood is resorbed. Some patients have surprisingly few neurologic deficits because hemorrhage is less destructive to brain tissue than infarction.

Small hemorrhages may cause focal deficits without impairment of consciousness and with minimal or no headache and nausea. Small hemorrhages may mimic ischemic stroke.

 

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A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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The correct answer is A. You answered A.

Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.

 

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?

Answer

 

Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The correct answer is A. You answered A.

The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.

 

 


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