Differential Diagnosis Intracerebral Hemorhage Disease Description It is a bleeding in the brain caused by the breaking or rupture of a blood vessel

in the head allowing blood to leak inside the brain. Pathophysiology Hypertensive intraparenchymal hemorrhage (hypertensive hemorrhage or hypertensive intracerebral hemorrhage) usually results from spontaneous rupture of a small penetrating artery deep in the brain. When hemorrhages occur in other brain areas or in nonhypertensive patients, greater consideration should be given to hemorrhagic disorders, neoplasms, vascular malformations, and other causes. The small arteries in these areas seem most prone to hypertension- induced vascular injury. The hemorrhage may be small or a large clot may form and compress adjacent tissue, causing herniation and death. Blood may dissect into the ventricular space, which substantially increases morbidity and may cause hydrocephalus. Most hypertensive intraparenchymal hemorrhages develop over 3090 min. Signs and Symptoms Classical Textbook Description Diminished level of consciousness Headache Vomiting Slurred speech Weakness or paralysis Hemiplegia and/or hemiparesis Aphasia and/or apraxia Ataxia Dizziness or vertigo Dysarthria or dysphagia Coma Diagnostic Evaluation Intracranial hemorrhage is often discovered on noncontrast CT imaging of the brain during the acute evaluation of stroke. Since CT is more sensitive than routine MRI for acute blood, CT imaging is the preferred method for acute stroke evaluation. Patients should have routine blood chemistries and hematologic studies. Specific attention to the platelet count and PT/PTT are important to identify coagulopathy. CT imaging reliably detects acute focal hemorrhages in the supratentorial space. MRI, though more sensitive for delineating posterior fossa lesions, is generally not necessary in most instances. Images of flowing blood on MRI Present in Patient Headache Diminished level of consciousness (unconscious) Weakness vomiting

scan may identify AVMs as the cause of the hemorrhage. MRI, CT angiography, and conventional x-ray angiography are used when the cause of intracranial hemorrhage is uncertain, particularly if the patient is young or not hypertensive and the hematoma is not in one of the four usual sites for hypertensive hemorrhage. Since patients typically have focal neurologic signs and obtundation, and often show signs of increased ICP, a lumbar puncture should be avoided as it may induce cerebral herniation. Treatment Nearly 50% of patients with a hypertensive intracerebral hemorrhage die, but others may have a good to complete recovery if they survive the initial hemorrhage. The volume and location of the hematoma determine the prognosis. In general, supratentorial hematomas with volumes <30 mL have a good prognosis; 3060 mL, an intermediate prognosis; and >60 mL, a poor prognosis during initial hospitalization. Extension into the ventricular system worsens the prognosis, as does advanced age, location within the posterior fossa, and depressed level of consciousness at initial presentation. Any identified coagulopathy should be reversed as soon as possible. For patients taking warfarin sodium, more rapid reversal of coagulopathy can be achieved by infusing prothrombin complex concentrates followed by fresh frozen plasma and vitamin K. For cerebellar hemorrhages, a neurosurgeon should be consulted immediately to assist with the evaluation; most cerebellar hematomas >3 cm in diameter will require surgical evacuation. If the patient is alert without focal brainstem signs and if the hematoma is <1 cm in diameter, surgical removal is usually unnecessary. For prevention, hypertension is the leading cause of primary intracerebral hemorrhage. Prevention is aimed at reducing hypertension, excessive alcohol use, and use of illicit drugs such as cocaine and amphetamines.