Chapter 428 Intracranial Hemorrhage PDF

University of the Philippines ­ Manila Access Provided by: Harrison's...

University of the Philippines ­ Manila Access Provided by: Harrison's Principles of Internal Medicine, 21e Chapter 428: Intracranial Hemorrhage Wade S. Smith; J. Claude Hemphill, III; S. Claiborne Johnston INTRODUCTION Intracranial hemorrhage is a form of stroke (see Chap. 426). Compared to ischemic stroke, patients with intracranial hemorrhage are more likely to present with headache; however, brain imaging is required to distinguish these entities. CT imaging of the head is highly sensitive and specific for intracranial hemorrhage and determines the location(s) of bleeding. Hemorrhages are classified by their location and the underlying vascular pathology. Hemorrhage directly into the brain parenchyma, also known as intracerebral hemorrhage (ICH), and arteriovenous malformations (AVMs) of the brain will be considered here. Other categories of hemorrhage include bleeding into subdural and epidural spaces, usually caused by trauma (Chap 443), and subarachnoid hemorrhage due to trauma or the rupture of an intracranial aneurysm (Chap. 429). DIAGNOSIS Intracranial hemorrhage is often identified on noncontrast CT imaging of the brain during the acute evaluation of stroke. Because CT is more widely available and may be logistically easier to perform than MRI, CT imaging is generally the preferred method for acute stroke evaluation (Fig. 428­1). The location of the hemorrhage narrows the differential diagnosis to a few entities. Table 428­1 lists the causes and anatomic spaces involved in hemorrhages. FIGURE 428­1 Hypertensive hemorrhage. Transaxial noncontrast computed tomography scan through the region of the basal ganglia reveals a hematoma involving the left putamen in a patient with rapidly progressive onset of right hemiparesis. TABLE 428­1 Downloaded 2024­8­4 6:23 A Your IP is 49.147.196.41 Causes of Intracranial Hemorrhage Chapter 428: Intracranial Hemorrhage, Wade S. Smith; J. Claude Hemphill, III; S. Claiborne Johnston Page 1 / 12 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility CAUSE LOCATION COMMENTS  University of the Philippines ­ Manila Access Provided by: TABLE 428­1 Causes of Intracranial Hemorrhage CAUSE LOCATION COMMENTS Head trauma Intraparenchymal: frontal lobes, anterior Coup and contrecoup injury during brain deceleration temporal lobes; subarachnoid; extra­axial (subdural, epidural) Hypertensive Putamen, globus pallidus, thalamus, Chronic hypertension produces hemorrhage from small (~30–100 μm) vessels in these hemorrhage cerebellar hemisphere, pons regions Transformation Basal ganglion, subcortical regions, lobar Occurs in 1–6% of ischemic strokes with predilection for large hemispheric infarctions of prior ischemic infarction Metastatic brain Lobar Lung, choriocarcinoma, melanoma, renal cell carcinoma, thyroid, atrial myxoma tumor Coagulopathy Any Risk for ongoing hematoma expansion Drug Any, lobar, subarachnoid Cocaine, amphetamine Arteriovenous Lobar, intraventricular, subarachnoid Risk is ~2–3% per year for bleeding if previously unruptured malformation Aneurysm Subarachnoid, intraparenchymal, rarely Mycotic and nonmycotic forms of aneurysms subdural Amyloid Lobar Degenerative disease of intracranial vessels; associated with dementia, rare in patients angiopathy