CEREBROVASCULAR ACCIDENT
    OR ―BRAIN ATTACK‖
 Third leading cause of death
 750, 000 cases/year
 Leading cause of sig...
Types of Stroke
 Ischemic, 80%
   - thrombosis, 50% (small & large-vessel)
   - embolism, 30%
 Hemorrhagic, 20%
   - int...
CEREBRAL HEMORRHAGE
 HEMORRHAGIC STROKE
 PRIMARY INTRACEREBRAL
  HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 HEMORRHAGE FROM ...
CEREBRAL HEMORRHAGE
 HEMORRHAGIC STROKE
 PRIMARY INTRACEREBRAL
  HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 HEMORRHAGE FROM ...
HEMORRHAGIC STROKE
 The transformation of a bland infarct into a
  hemorrhagic infarct is a common
  occurrence (highest ...
Right Middle Cerebral Artery Territory Infarct
Risk Factors For Hemorrhagic
    Transformation of a Bland Infarct
 Advanced age
 Embolization as etiology
 High systol...
HEMORRHAGIC INFARCT
CEREBRAL HEMORRHAGE
 HEMORRHAGIC STROKE
 PRIMARY INTRACEREBRAL
  HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 HEMORRHAGE FROM ...
RISK FACTORS FOR ICH
 Advancing age
 HTN (autopsy studies on patients with ICH
  showed high incidence of LVH;
  PROGRES...
PRIMARY INTRACEREBRAL
          HEMORRHAGE
   Five most common sites:
    putamen: 35 % - 50%
    subcortical white matte...
THE ANTERIOR CIRCULATION
 Most ICH originate from the rupture of
  small deep penetrating arteries (50 to 200
  um); most common: lenticulostriate...
Massive Right Putaminal Hemorrhage
Subcortical White Matter ICH
Pontine Hemorrhage
Thalamic Hemorrhage
Right Cerebellar Hemorrhage
CEREBRAL HEMORRHAGE
 HEMORRHAGIC STROKE
 PRIMARY INTRACEREBRAL
  HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 HEMORRHAGE FROM ...
SUBARACHNOID HEMORRHAGE
 Accounts for 5-10% of all strokes
 Incidence has not declined in 30 years
 80% due to rupture ...
RUPTURED ANEURYSM SITES: International
    Cooperative Study On The Timing Of Aneurysm Study

 Anterior communicating art...
CAUSES OF SUDDEN DEATH IN SAH

 Large intraparenchymal hematoma
 Destruction of brain tissue
 Acute hydrocephalus
 Inc...
LEADING CAUSES OF DEATH ON
       HOSPITALIZED PATIENTS
 Sequelae of initial hemorrhage
 Recurrent aneurysmal
 Vasospas...
CEREBRAL HEMORRHAGE
 HEMORRHAGIC STROKE
 PRIMARY INTRACEREBRAL
  HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 HEMORRHAGE FROM ...
CEREBRAL AMYLOID ANGIOPATHY

 Amyloid deposition in the cerebral vessels
  sufficient to cause symptomatic vascular
  dys...
HEMORRHAGE SECONDARY TO CEREBRAL
         AMYLOID ANGIOPATHY (CAA)

 Most common cause of lobar
  hemorrhages in non-hype...
RISK FACTORS FOR CAA LOBAR
            HEMORRHAGE
 Advanced age
 APOE epsilon2 or epsilon4
 Alzheimer’s disease
RISK FACTORS FOR NON-CAA ICH

 Family history of ICH
 Frequent use of alcohol
 Previous ischemic stroke
 Low serum cho...
ICH: EVALUATION AND WORK-UP:

   History and PE
   Computed Tomography (CT) scan of the head
   12-lead EKG, chest X-ra...
Other Neuroimaging Techniques &
         Ancillary Tests
 Magnetic Resonance Imaging (MRI)
  Diffusion Weighted Imaging (...
SUBACUTE INTRACEREBRAL HEMORRHAGE
Under special circumstances, the
    following tests may be required:
 Cervical spine x-ray
 Arterial blood gas
 Lumbar...
Glasgow Coma Scale

               1               2                 3                  4                 5               ...
Overview of ICH Management
    ICH has frequent early, ongoing bleeding and
    progressive deterioration, severe clinical...
CASE SPECIFIC MANAGEMENT

 Correctible/controllable causes of
  hemorrhage (e.g. warfarin)
 Clipping of aneurysm
Herniation
 Early clinical signs: mental status change,
  pupillary dilatation, vomiting
 Late clinical signs: ocular pa...
TREATMENT OF BRAIN
              SWELLING
     Cerebral perfusion pressure =MAP-ICP
   Fluid Restriction (1200 ml /day/m2...
Before Intraven-
tricular TPA




After
   INTRAVENTRICULAR HEMORRHAGE
Intracerebral hemorrhage has
     frequent early, ongoing
    bleeding and progressive
  deterioration, severe clinical
 d...
THANK YOU!
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of  Neurology University Of Nevada School Of Medicine
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Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of Neurology University Of Nevada School Of Medicine

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  • Thank you, Susan. You are already helping the community by passing on the information.
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  • Dear Dr. Valencia,
    Your information was VERY useful and informative to me and many of my close family members and friends. I will certainly forward this valuable information to those who aren't really sure what the signs, and most importantly the immediate treatment available. I find there are way too many people out there that wait till it too late for treatment. This information will most certainly give myself and others the information and signs to look for in any potential stroke onsets.
    Thank you for this invaluable knowledge and education, you are truly a very well educated and very compassionate doctor. Those are the two qualities that make you very approachable and non-judgement. In my own opinion, I was not afraid to ask questions and found your answers very helpful.
    God Bless & Keep up the GREAT work!
    Susan Maynard -Reno, NV
       Reply 
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Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor Of Neurology University Of Nevada School Of Medicine

  1. 1. CEREBROVASCULAR ACCIDENT OR ―BRAIN ATTACK‖  Third leading cause of death  750, 000 cases/year  Leading cause of significant disability  Cost: $40 billion/year
  2. 2. Types of Stroke  Ischemic, 80% - thrombosis, 50% (small & large-vessel) - embolism, 30%  Hemorrhagic, 20% - intracerebral (HTN as risk) - subarachnoid (aneurysm)
  3. 3. CEREBRAL HEMORRHAGE  HEMORRHAGIC STROKE  PRIMARY INTRACEREBRAL HEMORRHAGE  SUBARACHNOID HEMORRHAGE  HEMORRHAGE FROM CEREBRAL AMYLOID ANGIOPATHY
  4. 4. CEREBRAL HEMORRHAGE  HEMORRHAGIC STROKE  PRIMARY INTRACEREBRAL HEMORRHAGE  SUBARACHNOID HEMORRHAGE  HEMORRHAGE FROM CEREBRAL AMYLOID ANGIOPATHY
  5. 5. HEMORRHAGIC STROKE  The transformation of a bland infarct into a hemorrhagic infarct is a common occurrence (highest in autopsy studies)  ―The concept of migratory embolus‖
  6. 6. Right Middle Cerebral Artery Territory Infarct
  7. 7. Risk Factors For Hemorrhagic Transformation of a Bland Infarct  Advanced age  Embolization as etiology  High systolic BP  CT shows mass effect  Larger territory strokes  Anticoagulation  History of coagulopathy
  8. 8. HEMORRHAGIC INFARCT
  9. 9. CEREBRAL HEMORRHAGE  HEMORRHAGIC STROKE  PRIMARY INTRACEREBRAL HEMORRHAGE  SUBARACHNOID HEMORRHAGE  HEMORRHAGE FROM CEREBRAL AMYLOID ANGIOPATHY
  10. 10. RISK FACTORS FOR ICH  Advancing age  HTN (autopsy studies on patients with ICH showed high incidence of LVH; PROGRESS – Perindopril Protection Against Recurrent Stroke Study:76% relative risk reduction of ICH in comparison to placebo  Cigarette smoking  alcoholism
  11. 11. PRIMARY INTRACEREBRAL HEMORRHAGE  Five most common sites: putamen: 35 % - 50% subcortical white matter 30% thalamus: 10%-15% pons 5%-12% cerebellar white matter <5%
  12. 12. THE ANTERIOR CIRCULATION
  13. 13.  Most ICH originate from the rupture of small deep penetrating arteries (50 to 200 um); most common: lenticulostriates  Same arteries are recognized to be occluded in lacunar infarcts (process: fibrinoid necrosis or lipohyalinosis)
  14. 14. Massive Right Putaminal Hemorrhage
  15. 15. Subcortical White Matter ICH
  16. 16. Pontine Hemorrhage
  17. 17. Thalamic Hemorrhage
  18. 18. Right Cerebellar Hemorrhage
  19. 19. CEREBRAL HEMORRHAGE  HEMORRHAGIC STROKE  PRIMARY INTRACEREBRAL HEMORRHAGE  SUBARACHNOID HEMORRHAGE  HEMORRHAGE FROM CEREBRAL AMYLOID ANGIOPATHY
  20. 20. SUBARACHNOID HEMORRHAGE  Accounts for 5-10% of all strokes  Incidence has not declined in 30 years  80% due to rupture of intracranial saccular aneurysm  30-day mortality rate 50%  Most deaths occur within one week
  21. 21. RUPTURED ANEURYSM SITES: International Cooperative Study On The Timing Of Aneurysm Study  Anterior communicating artery (ACom) 34%  ICA 30%  MCA 22%  Basilar tip, PICA, basilar trunk branches— 7.6%
  22. 22. CAUSES OF SUDDEN DEATH IN SAH  Large intraparenchymal hematoma  Destruction of brain tissue  Acute hydrocephalus  Increased intracranial pressure  Cardiac arrhythmias, MI, PE and respiratory failure
  23. 23. LEADING CAUSES OF DEATH ON HOSPITALIZED PATIENTS  Sequelae of initial hemorrhage  Recurrent aneurysmal  Vasospasm leading to ischemic stroke  Severe medical complications
  24. 24. CEREBRAL HEMORRHAGE  HEMORRHAGIC STROKE  PRIMARY INTRACEREBRAL HEMORRHAGE  SUBARACHNOID HEMORRHAGE  HEMORRHAGE FROM CEREBRAL AMYLOID ANGIOPATHY
  25. 25. CEREBRAL AMYLOID ANGIOPATHY  Amyloid deposition in the cerebral vessels sufficient to cause symptomatic vascular dysfunction  Vessel rupture and spontaneous ICH untreatable and unpreventable  Prevalence of CAA: 2.3% age 65-74; 8% age 75-84 ;12.1% 85 and older
  26. 26. HEMORRHAGE SECONDARY TO CEREBRAL AMYLOID ANGIOPATHY (CAA)  Most common cause of lobar hemorrhages in non-hypertensive individuals  Elderly patients  Evidence of small microbleeds in MRI  Long-term recurrence increased
  27. 27. RISK FACTORS FOR CAA LOBAR HEMORRHAGE  Advanced age  APOE epsilon2 or epsilon4  Alzheimer’s disease
  28. 28. RISK FACTORS FOR NON-CAA ICH  Family history of ICH  Frequent use of alcohol  Previous ischemic stroke  Low serum cholesterol level
  29. 29. ICH: EVALUATION AND WORK-UP:  History and PE  Computed Tomography (CT) scan of the head  12-lead EKG, chest X-ray  Complete blood count, PT, PTT  Chemistries (sodium, phosphate, glucose abnormalities may mimic stroke)  Urine and serum toxicology (drugs and alcohol)
  30. 30. Other Neuroimaging Techniques & Ancillary Tests  Magnetic Resonance Imaging (MRI) Diffusion Weighted Imaging (DWI), Magnetic Resonance Angiography (MRA)  Ultrasound (Carotid Duplex, Transcranial Doppler, 2-D echo)  Conventional Angiography
  31. 31. SUBACUTE INTRACEREBRAL HEMORRHAGE
  32. 32. Under special circumstances, the following tests may be required:  Cervical spine x-ray  Arterial blood gas  Lumbar puncture  Electroencephalogram (EEG)
  33. 33. Glasgow Coma Scale 1 2 3 4 5 6 Opens eyes in Opens eyes in Does not open Opens eyes Eyes response to response to N/A N/A eyes spontaneously painful stimuli voice Utters Oriented, Makes no Incomprehensibl Confused, Verbal inappropriate converses N/A sounds e sounds disoriented words normally Abnormal Flexion / Makes no Extension to Localizes Obeys Motor flexion to painful Withdrawal to movements painful stimuli painful stimuli Commands stimuli painful stimuli
  34. 34. Overview of ICH Management ICH has frequent early, ongoing bleeding and progressive deterioration, severe clinical deficits and subsequent high mortality and morbidity rates  Good general supportive management (airways, oxygenation, circulation, glucose level, fever, DVT prophylaxis)  Slowing or stopping initial bleeding  Blood removal from parenchyma or ventricles  Management of complications of blood in the rain (increased ICP, decreased CPP)
  35. 35. CASE SPECIFIC MANAGEMENT  Correctible/controllable causes of hemorrhage (e.g. warfarin)  Clipping of aneurysm
  36. 36. Herniation  Early clinical signs: mental status change, pupillary dilatation, vomiting  Late clinical signs: ocular paresis, decerebrate rigidity, coma and death
  37. 37. TREATMENT OF BRAIN SWELLING Cerebral perfusion pressure =MAP-ICP  Fluid Restriction (1200 ml /day/m2)  Controlled hyperventilation: 25 mm Hg  Mannitol, 0.25 mg/kg IV over 20 minutes; repeat PRN, serum osmolality maintained in the range of 300- 320mOsm/l  Barbiturate coma, with ICP monitoring (subrachnoid bolt, IV catheter or Camino catheter): maintain CPP greate than 50 mmHg; pentobarbtial serum level of 2-4 mg/dl  Drainage of CSF (ventriculostomy)  Lobectomy
  38. 38. Before Intraven- tricular TPA After
  39. 39.  INTRAVENTRICULAR HEMORRHAGE
  40. 40. Intracerebral hemorrhage has frequent early, ongoing bleeding and progressive deterioration, severe clinical deficits and subsequent high mortality and morbidity rates.
  41. 41. THANK YOU!

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