intra cranial hemorrhage
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intra cranial hemorrhage
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intra cranial hemorrhage
- 2. Location • Epidural • Subdural • Sub arachnoid • Intra cerebral • 1and 2 and 3 is due to trauma • 4 is due to aneurysm and AVM..
- 3. Diagnosis • Non contrast CT imaging oAcute oAvailable oType oLocation • MRI • CT angiography • Catheter angiography
- 4. Emergency Management Airway (reduction in the level of consciousness) Blood pressure (until result of CT scan coming ) Transport patient ED should be prepared Neurology and neuroradiology ICP management
- 5. Common causes • Hypertension • Coagulopathy • Drugs (methamphetamine and cocaine ) in young • Cerebral amyloid angiopathy • Advanced age • Heavy alcohol consumption
- 6. Hypertensive intracerebral hemorrhage • Usually results from spontaneous rupture of small penetrating artery in deep brain • The most common sites is basal ganglia (putamen specially) • Thalamus , cerebellum and pons • The small arteries in this areas seem the most prone to hypertensive induced vascular injury
- 7. Cont.… • When hemorrhage occur in other brain areas or in non hypertensive patient • Neoplasms • Vascular malformation • Cerebral amyloid angiopathy
- 8. Time of hemorrhage • The most hypertensive ICH develop in 30-90 min • Anticoagulant therapy associated ICH may develop up to 24-48 h • Macrophage phagocyte hematoma farm outer surface in 1-6 months
- 9. Clinical manifestation • ICH has a abrupt onset of focal neurological deficit • Seizures are common • Diminishing level of consciousness • Signs of increased ICP(headache and vomiting )
- 10. Putamen • The putamen is the common site of hypertensive ICH and adjacent internal capsule is damage 1. Contralateral hemiparesis 2. Speech becomes slurred 3. The arm and leg gradually weaken 4. The eye deviate away from the site of hemiparesis 5. The paresis may be worsen until the affected limbs become flaccid or extend rigidly 6. Drowsiness, stupor and coma
- 11. Thalamic hemorrhage • Contralateral hemiplegia or paresis • Prominent sensory deficit • Aphasia often with verbal repetition • Several ocular disturbance • Unequal pupils with absence of light reaction • Pinpoint pupil (in coma ) •
- 12. Lobar hemorrhage • The major neurological deficit with a occiptal hemorrhage is hemianopia • Left temporal hemorrhage is aphasia and delirium • Partial hemorrhage is hemi sensory loss • Frontal hemorrhage, arm weakness • The most patients with lobar hemorrhage has focal headache
- 13. Hemorrhage in tumor • Hemorrhage in brain tumor is may be the first manifestation of neoplasm • Choriocarcinoma • malignant melanoma • Renal cell carcinoma
- 14. Hypertensive encephalopathy • Complication of malignant hypertension • Headache • Nausea • Vomiting • Confusion, coma • Retinal hemorrhage , exudate, papilledema • Evidence of renal and cardiac disease
- 15. Laboratory and imaging evaluation • CBC • PT,PTT,INR • CT, CT scan angio • MRI • Catheter angiography
- 16. BP control • Good BP is >140 mmhg • No change seen in BP 140-180 mmhg • Labetalol • Nicardipine • Esmolol
- 17. Glucose management • High blood glucose is increased risk of mortality • Good blood glucose is 80-110 mg/dl • Hypoglycemia should be avoided
- 18. ICP treatment • Elevation of head 30 • Mild sedation • Mannitol or hypertonic slain • Ventricular drainage for hydrocephalus • Corticosteroids not administered
- 19. Temperature management • Fever is common after ICH • Fever is worsens the brain injury • Cooling may reduce perihematomal edema
- 20. Management of medical complication • Dysphagia taken oral foods • Aspiration pneumonia • Myocardial ischemia or infarction with electrocardiogram and cardiac enzyme • KFT for kidney saving
- 21. Thromboprophylaxis in ICH • Intermittent pneumatic compression • IVC filter
- 22. Treatment • Any identified coagulopathy should be corrected as soon as possible • Vitamin K • Prothrombin complex • Fresh frozen plasma • Platelet transfusion (>50,000)
- 23. Cont.. • Dabidatran, revaroxaban and apixaban • For> 2 hours activated charcoal • hemodialysis
- 24. Cot.. • Protamine sulfate • For patient take heparin in acute ICH
- 25. References • Current 2018 • American heart association • Harrison