Intraparenchymal Hemorrhage

2. INTRO....
• It is a type of intracerebral hemorrhage , in which
there is bleeding within brain parenchyma.
• Accounts for < 10% of all strokes & is associated
with about 50% case fatality rate.
• Incidence rate is particularly high amoung Asians
possibly due to environmental /genetic factors.

3. AETIOLOGY
1. Hypertension
2. Cerebral amyloid angiopathy
3. Head trauma
4. Vascular malformations
5. Hemorrhagic disorders
6. Neoplasm
7. Drug abuse

4. Hypertensive intraparenchymal
hemorrhage
• Usually results from hypertension induced vascular
injury i.e by spontaneous rupture of small
penetrating arteries deep in the brain as a result of
chronic wear and tear due to high BP.
• COMMON SITES : Basal ganglia ( Putamen)
Thalamus
Cerebellum
Pons

5. • The hemorrhage may be a small or large clot , may
compress the adjacent brain tissue causing
herniation and death.
• Blood may dissect into the ventricular space which
substantially increase the morbidity.
• Within 48 hrs macrophages begin to phagocytise
the hemorrhage at its outer surface , generally
resolved to a slit like cavity lined with glial scar and
hemosiderin laiden macrophages.

6. CLINICAL FEATURES
• Generally presents as abrupt onset of focal
neurological deficits which typically worsen steadily
over 30-90 mins and is associated with
1. Diminished level of consciousness
2. Signs of raised ICT : headache , projectile vomiting
, neck rigidity.
• seizures are uncommon

7. FOCAL NUROLOGICAL DEFICITS
PUTAMEN
• Contralateral hemiparesis ( sentinel sign)
• When small
A. Face sags on one side over 5-30 min
B. Speech becomes slurred
C. Limbs gradually weaken
D. Eyes deviate away from side of paresis

8. • When large
A. Drowsiness gives way to stupor as signs of upper
brainstem compression appear
B. Coma appears accompanied by
Deep irregular or intermittent respiration
Dilated and fixed ipsilateral pupil
Bilateral babinski sign & rigidity

9. THALAMIC HAEMORRHAGE
• Contralateral hemiplegia / hemiparesis from
pressure on or dissection into the adjacent internal
capsule.
• Prominent sensory deficit .
• Aphasia with preserved verbal repetition may occur
after hemorrhage into dominant thalamus &
constructional aphasia/mutism in cases of
nondominant hemorrhage.
• Typical ocular disturbances by virtue of its extension
medially into upper midbrain. These include

10. i. Deviation of eyes downward & inward so that they
appears to be looking at the nose.
ii. Unequal pupils with absence of light reaction.
iii. Skew deviation with eye opposite the hemorrhage
displaced downward & medially.
iv. Ipsilateral Horner’s Syndrome.
v. Absence of convergence.
vi. Paralysis of vertical gaze.
vii. Retraction nystagmus..

11. PONTINE HEMORRHAGE
I. Deep coma with quadriplegia over a few min.
II. Pinpoint pupil reacting to light.
III. Impaired reflex horizontal eye movement evoked
by head turning or by irrigation of ears with ice
water.
IV. Hyperpnea , Hyperhydrosis , Hypertension..

12. CEREBELLAR HEMORRHAGE
I. Occipital headache.
II. Repeated vomiting.
III. Ataxia.
IV. Dizziness
V. Paresis of conjugate lateral gaze towards side of
haemorrhage , forced deviation of eyes to
opposite side or ipsilateral VI th nerve palsy
VI. Dysarthria & dysphagia may occur

13. LOBAR HAEMMORHAGE
• Usually small & simulates an embolus to an artery
supplying one lobe and cause a restricted clinical
syndrome such as
the major neurological deficit with
I. Occipital haemorrhage – Hemianopia
II. Left temporal hemorrhage - Aphasia & Delirium
III. Parietal hemorrhage – Hemi sensory loss
IV. Frontal hemorrhage – Arm weakness
• If large , may be associated with stupor or coma if
they compress the thalamus or mid brain.
• Focal headache & Vomiting are common.

14. Other Causes in brief.....
Cerebral Amyloid Angiopathy
• Disease of elderly characterized by
Arteriolar degeneration &
Amyloid deposition in the walls of cerebral
arteries.
• Most common cause of lobar hemorrhage in the
elderly.

15. Drug Abuse
• Cocaine & Methamphetamine are the frequent
causes of stroke in young patients (age < 45 yrs).
• Cocaine enhances symapathetic activity causing
acute , sometimes severe hypertension leading to
hemorrhage.

16. Hematologic Disorders
Leukemia
Aplastic anaemia
Thrombocytopenic purpura.
• Can occur at any site & may presents as multiple
bleeds.
• Skin & Mucous membrane is usually evident &
offers a diagnostic clue..

17. TUMOUR
• Hemorrhage into brain tumour may be the first
manifestation of neoplasm
• Choriocarcinoma, malignant melanoma , RCC &
bronchogenic ca are the most common metastic
tumour associated with ich
VASCULAR MALFORMATIONS
• Arterio – venous malformation
• Capillary telangactasia
• Cavernous angioma
ICH ASSOCIATED WITH ANTICOAGULANT THERAPY
CAN OCCUR AT ANY SITE EVOLVES SLOWLY OVER
24-48 hrs