This document discusses intraparenchymal hemorrhage (IPH), which is bleeding within the brain tissue. IPH accounts for 8-13% of strokes and has a higher risk of death or disability than other types of strokes. The bleeding can disrupt or compress brain tissue. Common causes include hypertension, drug abuse, aneurysms, and cerebral amyloid angiopathy. Symptoms depend on the location and size of the bleeding in the brain and may include headaches, neurological deficits, and altered consciousness. Treatment involves controlling bleeding, reducing swelling and pressure in the brain, and managing symptoms. The case presented is an 81-year-old man with IPH likely due to hypertension.

1. INTRAPARENCYMAL HEMORRHAGE IPH presentation by Mwebaza Victor
Lobus frontalis,
parietal, temporalis
intraparenchymal
hemorrhage
Multiple intraparenchymal hemorrhage
Intraparenchymal hemorrhage (IPH) is one extension of intracerebral hemorrhage (the other is
intraventricular hemorrhage (IVH)) with bleeding within brain parenchyma.
Intraparenchymal hemorrhage accounts for approx. 8-13% of all strokes and results from a wide
spectrum of disorders. It is more likely to result in death or major disability than ischemic stroke or
subarachnoid hemorrhage, and therefore constitutes an immediate medical emergency. Intracerebral

2. hemorrhages and accompanying edema may disrupt or compress adjacent brain tissue, leading to
neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of
intracranial pressure (ICP) and potentially fatal herniation syndromes.
Pathophysiology
Nontraumatic intraparenchymal hemorrhage most commonly results from hypertensive damage to
blood vessel walls e.g.: - hypertension - eclampsia - drug abuse, but it also may be due to autoregulatory
dysfunction with excessive cerebral blood flow e.g.: - reperfusion injury - hemorrhagic transformation -
cold exposure - rupture of an aneurysm or arteriovenous malformation (AVM) - arteriopathy (e.g.
cerebral amyloid angiopathy, moyamoya) - altered hemostasis (e.g. thrombolysis, anticoagulation,
bleeding diathesis) - hemorrhagic necrosis (e.g. tumor, infection) - venous outflow obstruction (e.g.
cerebral venous sinus thrombosis). Nonpenetrating and penetrating cranial trauma can also be common
causes of intracerebral hemorrhage.
Physical Symptoms
Clinical manifestations of intraparenchymal hemorrhage are determined by the size and location of
hemorrhage, but may include the following:
Hypertension, fever, or cardiac arrhythmias
Nuchal rigidity
Subhyaloid retinal hemorrhages
Altered level of consciousness
Anisocoria, Nystagmus
Focal neurological deficits
Putamen - Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis,
homonymous hemianopsia, aphasia, neglect, or apraxia
Thalamus - Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia,
miosis, aphasia, or confusion
Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous
hemianopia, abulia, aphasia, neglect, or apraxia
Caudate nucleus - Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion

3. Brain stem - Tetraparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular
bobbing, miosis, or autonomic instability
Cerebellum - Ataxia, usually beginning in the trunk, ipsilateral facial weakness, ipsilateral sensory loss,
gaze paresis, skew deviation, miosis, or decreased level of consciousness
Causes
Hypertension
Arteriovenous malformation
Aneurysm rupture
Cerebral amyloid angiopathy
Intracranial neoplasm
Coagulopathy
Hemorrhagic transformation of an ischemic infarct
Cerebral venous thrombosis
Sympathomimetic drug abuse
Moyamoya
Sickle cell disease
Eclampsia or postpartum vasculopathy
Infection
Vasculitis
Neonatal intraventricular hemorrhage
Trauma
Diagnosis
Computed tomography (CT scan): A CT scan may be normal if it is done soon after the onset of
symptoms. A CT scan is the best test to look for bleeding in or around your brain. In some hospitals, a
perfusion CT scan may be done to see where the blood is flowing and not flowing in your brain.

4. Magnetic resonance imaging (MRI scan): A special MRI technique (diffusion MRI) may show evidence of
an ischemic stroke within minutes of symptom onset. In some hospitals, a perfusion MRI scan may be
done to see where the blood is flowing and not flowing in your brain.
Angiogram: a test that looks at the blood vessels that feed the brain. An angiogram will show whether
the blood vessel is blocked by a clot, the blood vessel is narrowed, or if there is an abnormality of a
blood vessel known as an aneurysm.
Carotid duplex: A carotid duplex is an ultrasound study that assesses whether or not you have
atherosclerosis (narrowing) of the carotid arteries. These arteries are the large blood vessels in your
neck that feed your brain.
Transcranial Doppler (TCD): Transcranial Doppler is an ultrasound study that assesses whether or not
you have atherosclerosis (narrowing) of the blood vessels inside of your brain. It can also be used to see
if you have emboli (blood clots) in your blood vessels.
Treatment
Intracerebral hemorrhages is a severe condition requiring prompt medical attention. Treatment goals
include lifesaving interventions, supportive measures, and control of symptoms. Treatment depends on
the location, extent, and cause of the bleeding. Often, treatment can reverse the damage that has been
done.
A craniotomy is sometimes done to remove blood, abnormal blood vessels, or a tumor. Medications
may be used to reduce swelling, prevent seizures, lower blood pressure, and control pain.
Acute intraparenchymal hemorrhage
Clinical History: An 81-year-old diabetic male presents with a change in mental status.
Findings: Axial CT images through the brain demonstrate two areas of hyperdensity, one measuring
approximately 2 x 1.5 cm and a second measuring approximately 3 x 4 cm. There is some surrounding

5. edema with mass effect upon the left ventricle. In addition, there is extension into the ventricular
system.
Diagnosis: Acute intraparenchymal hemorrhage.
Discussion: There are many causes for intraparenchymal hemorrhage. A common cause is secondary to
hypertension. These most commonly occur within the basal ganglia, subcortical white matter,
cerebellum, thalamus and pons. Hemorrhage into the posterior fossa with mass effect or extension into
the ventricular system carries poor prognosis.
In younger patients, vascular malformations, specifically AVMs and cavernous angiomas are more
common causes for hemorrhage. In addition, venous malformations are associated with hemorrhage.
In the elderly population, amyloid angiopathy is associated with cerebral infarcts as well as hemorrhage
in superficial locations, rather than deep white matter or basal ganglia. These are usually described as
"lobar". These bleedings are not associated with systemic amyloidosis.
Hemorrhagic neoplasms are more complex, heterogeneous bleeds often with associated edema. These
hemorrhages are related to tumor necrosis, vascular invasion and neovascularity. Glioblastomas are the
most common primary malignancies to hemorrhage while thyroid, renal cell carcinoma, melanoma, and
lung cancer are the most common causes of hemorrhage from metastatic disease.
Other causes of intraparenchymal hemorrhage include hemorrhagic transformation of infarction which
is usually in a classic vascular distribution and is seen in approximately
24 to 48 hours following the ischemic event. This hemorrhage
rarely extends into the ventricular system.
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