Intracranial vascular hemorrhage

Primary intracerebral hemorrhage is more common than subarachnoid hemorrhage, and its incidence increases with age (see Fig. 1.1). It is more frequent in Southeast Asian, Japanese and Chinese populations than in whites. The most common causes are intracranial small vessel disease, which is associated with hypertension, cerebral amyloid angiopathy and intracranial vascular malformations (Sutherland and Auer 2006). Rarer causes include saccular aneurysms, hemostatic defects, particularly those induced by anticoagulation or therapeutic thrombolysis, antiplatelet drugs, infective endocarditis, cerebral vasculitis and recreational drug use (Neiman et al. 2000 O Connor et al. 2005). 

Brown RD Jr, Wiebers DO, Torner JC et al. (1996b) Frequency of intracranial hemorrhage as a presenting symtom and subtype analysis a population-based study of intracranial vascular malformations in Olmsted Country, Minnesota. J Neurosurg 85 29-32... 

Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway s lesions... 

In subarachnoid hemorrhage due to a ruptured intracranial aneurysm or arteriovenous malformation, surgical intervention to clip or ablate the vascular abnormality substantially reduces mortality from rebleeding. The benefits of surgery are less well documented in cases of primary intracerebral hemorrhage. In patients with intracerebral hematomas, insertion of an intraventricular drain with monitoring of intracranial pressure is... 

Neurological involvement in Behcet s disease may be subclassified into two major forms a vascular-inflammatory process with focal or multifocal parenchymal involvement and a cerebral venous sinus thrombosis with intracranial hypertension. The vasculitis and meningitis may affect cerebral arteries, particularly in the posterior circulation, to cause ischemic stroke and possibly intracranial hemorrhage (Farah et al. 1998 Krespi et al 2001 Siva et al. 2004 Borhani Haghighi et al. 2005). 

The hematoma continues to expand after stroke onset, frequently causing further deterioration (Brott et al. 1997 Leira et al. 2004). Some brainstem hemorrhages evolve subacutely, particularly those caused by a vascular malformation (O Laoire et al. 1982 Howard 1986). Any large hematoma may cause brain shift, transtentorial herniation, brainstem compression and raised intracranial pressure. Hematomas in the posterior fossa are particularly likely to cause obstructive hydrocephalus. Rupture into the ventricles or on to the surface of the brain is common, causing blood to appear in the subarachnoid space. 

Gradual onset of stroke over hours or days, rather than seconds or minutes, is unusual and is much more likely to occur in ischemic than in hemorrhagic stroke. If the onset is gradual, and not Ukely to be caused by low flow or migraine (Ch. 8), then a structural intracranial lesion must be excluded. In younger patients, multiple sclerosis should also be considered. However, focal neurological deficits that develop over hours, or up to two days, in elderly patients are still most likely to have a vascular cause since vascular disease is so common in older patients. 

The main clinical indications for imaging the cerebral circulation are TIA (e.g. to identify arterial stenosis), acute ischemic stroke (e.g. to identify vessel occlusion), intracerebral hemorrhage (e.g. to identify an underlying vascular malformation) and possible arterial dissection, flbromuscular dysplasia or other arteriopathies, cerebral aneurysm, intracranial venous thrombosis or cerebral vasculitis. 

A 44-year-old man developed a severe headache and vomiting after taking four tablets of sildenafil (of unknown strength) followed by sexual intercourse (14). A CT scan showed a left-sided temporal intracranial hemorrhage. He died of cerebral edema and pneumonia a few days later. Autopsy showed no vascular abnormality. 

A course of ECT generally consists of 6 to 12 treatments administered either unilaterally or bilaterally two to three times weekly. A rapid therapeutic response (10 to 14 days) has been reported. Although there are no absolute contraindications to the use of ECT, several conditions are associated with increased risk. These include increased intracranial pressure, cerebral lesions, recent myocardial infarction, recent intracerebral hemorrhage, bleeding, or otherwise unstable vascular condition. The use of an anesthetic as well as a nondepolarizing neuromuscular blocking agent decreases the morbidity associated with ECT. ... 

Interest in thrombolytic therapy for acute ischemic stroke re-emerged with reports of successful thrombolysis for arterial thrombosis in the peripheral vascular system. Local lA infusion was found to have higher rates of recanalization compared with systemic IV delivery of thrombolytics without increased levels of hemorrhagic complications IV use of UK and SK was found to provide clinical benefit in patients with pulmonary embolism [5, 6]. In the early 1980s, lA infusion of UK or SK for acute MI was shown to be highly effective [5, 6]. At the same time, technical advances in endovascnlar microcatheter and microguidewire design made access to the intracranial vessels safer... 

History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor [may consider iv t-PA in patients with CNS lesions that have a very low likelihood of bleeding such as small unruptured aneurysms or benign tumors with low vascularity]... 

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