Intraparenchymal hemorrhage
Encyclopedia
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 stroke
s 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
. Intracerebral 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.
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 be also common causes of intracerebral hemorrhage.
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.
A craniotomy
is sometimes done to remove blood, abnormal blood vessels, or a tumor. Medications may be used to reduce swelling, prevent seizure
s, lower blood pressure
, and control pain.
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 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 angioma
s 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.
Intraventricular hemorrhage
An intraventricular hemorrhage , often abbreviated "IVH," is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space...
(IVH)) with bleeding within brain parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
.
Intraparenchymal hemorrhage accounts for approx. 8-13% of all stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
s and results from a wide spectrum of disorders. It is more likely to result in death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....
or major disability
Disability
A disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...
than ischemic stroke or subarachnoid hemorrhage
Subarachnoid hemorrhage
A subarachnoid hemorrhage , or subarachnoid haemorrhage in British English, is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain...
. Intracerebral hemorrhages and accompanying edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
(ICP) and potentially fatal herniation syndromes.
Pathophysiology
Nontraumatic intraparenchymal hemorrhage most commonly results from hypertensive damage to blood vesselBlood vessel
The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
walls e.g.:
- hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
- eclampsia
Eclampsia
Eclampsia , an acute and life-threatening complication of pregnancy, is characterized by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-eclampsia...
- drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
,
but it also may be due to autoregulatory
Autoregulation
Autoregulation is a process within many biological systems, resulting from some internal adaptive mechanism that works to adjust the systems response to stimuli. While most systems of the body show some degree of autoregulation, it is most clearly observed in the kidney, the heart, and the brain...
dysfunction with excessive cerebral blood flow e.g.:
- reperfusion injury
Reperfusion injury
Reperfusion injury is the tissue damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen. The absence of oxygen and nutrients from blood during the ischemic period creates a condition in which the restoration of circulation results in inflammation and...
- hemorrhagic transformation
- cold exposure
- rupture of an aneurysm
Aneurysm
An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
or arteriovenous malformation
Arteriovenous malformation
Arteriovenous malformation or AVM is an abnormal connection between veins and arteries, usually congenital. This pathology is widely known because of its occurrence in the central nervous system, but can appear in any location. An arteriovenous malformation is a vascular anomaly. It is a...
(AVM)
- arteriopathy (e.g. cerebral amyloid angiopathy, moyamoya)
- altered hemostasis
Hemostasis
Hemostasis or haemostasis is a process which causes bleeding to stop, meaning to keep blood within a damaged blood vessel . Most of the time this includes blood changing from a liquid to a solid state. Intact blood vessels are central to moderating blood's tendency to clot...
(e.g. thrombolysis
Thrombolysis
Thrombolysis is the breakdown of blood clots by pharmacological means. It is colloquially referred to as clot busting for this reason...
, anticoagulation, bleeding diathesis
Bleeding diathesis
In medicine , bleeding diathesis is an unusual susceptibility to bleeding mostly due to hypocoagulability, in turn caused by a coagulopathy . Several types are distinguished, ranging from mild to lethal...
)
- hemorrhagic necrosis (e.g. tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
)
- venous outflow obstruction (e.g. cerebral venous sinus thrombosis
Cerebral venous sinus thrombosis
Cerebral venous sinus thrombosis is a rare form of stroke that results from thrombosis of the dural venous sinuses, which drain blood from the brain. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body, and...
).
Nonpenetrating and penetrating cranial trauma can be also 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, feverFeverFever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, or cardiac arrhythmias - Nuchal rigidity
- Subhyaloid retinal hemorrhages
- Altered level of consciousnessAltered level of consciousnessAn altered level of consciousness is any measure of arousal other than normal. Level of consciousness is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousness may be classed as lethargy; someone in this state can be...
- AnisocoriaAnisocoria-Causes:In the absence of the iris or eyeball proper, anisocoria is usually the result of a defect in efferent nervous pathways controlling the pupil traveling in the oculomotor nerve or the sympathetic pathways...
, NystagmusNystagmusNystagmus is a condition of involuntary eye movement, acquired in infancy or later in life, that may result in reduced or limited vision.There are two key forms of Nystagmus: pathological and physiological, with variations within each type. Nystagmus may be caused by congenital disorders,... - Focal neurological deficits
- PutamenPutamenThe putamen is a round structure located at the base of the forebrain . The putamen and caudate nucleus together form the dorsal striatum. It is also one of the structures that comprises the basal ganglia. Through various pathways, the putamen is connected to the substantia nigra and globus pallidus...
- Contralateral hemiparesisHemiparesisHemiparesis is weakness on one side of the body. It is less severe than hemiplegia - the total paralysis of the arm, leg, and trunk on one side of the body. Thus, the patient can move the impaired side of his body, but with reduced muscular strength....
, contralateral sensory loss, contralateral conjugate gaze paresis, homonymous hemianopsiaHomonymous hemianopsiaHemianopsia or hemianopia is visual field loss that respects the vertical midline, and usually affects both eyes, but can involve one eye only. Homonymous hemianopsia, or homonymous hemianopia occurs when there is hemianopic visual field loss on the same side of both eyes...
, aphasiaAphasiaAphasia is an impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write....
, neglect, or apraxiaApraxiaApraxia is a disorder caused by damage to specific areas of the cerebrum. Apraxia is characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements... - ThalamusThalamusThe thalamus is a midline paired symmetrical structure within the brains of vertebrates, including humans. It is situated between the cerebral cortex and midbrain, both in terms of location and neurological connections...
- Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia, miosisMiosisMiosis is the constriction of the pupil of the eye to two millimeters or less...
, aphasia, or confusion - Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, abulia, aphasia, neglect, or apraxia
- Caudate nucleusCaudate nucleusThe caudate nucleus is a nucleus located within the basal ganglia of the brains of many animal species. The caudate nucleus is an important part of the brain's learning and memory system.-Anatomy:...
- Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion - Brain stemBrain stemIn vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...
- Quadriparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular bobbing, miosis, or autonomic instability - CerebellumCerebellumThe cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
- AtaxiaAtaxiaAtaxia is a neurological sign and symptom that consists of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum...
, usually beginning in the trunk, ipsilateral facial weakness, ipsilateral sensory loss, gaze paresis, skew deviationSkew deviationSkew deviation is an unusual ocular deviation , wherein the eyes move upward , but in opposite directions. Skew deviation is caused by abnormal prenuclear vestibular input to the ocular motor nuclei, most commonly due to brainstem or cerebellar stroke. Other causes include multiple sclerosis and...
, miosis, or decreased level of consciousness
Causes
- Hypertension
- Arteriovenous malformation
- Aneurysma rupture
- Cerebral amyloid angiopathy
- Intracranial neoplasm
- CoagulopathyCoagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
- Hemorrhagic transformation of an ischemic infarct
- Cerebral venous thrombosis
- Sympathomimetic drug abuse
- Moyamoya
- Sickle cell disease
- Eclampsia or postpartum vasculopathy
- Infection
- VasculitisVasculitisVasculitis refers to a heterogeneous group of disorders that are characterized by inflammatory destruction of blood vessels. Both arteries and veins are affected. Lymphangitis is sometimes considered a type of 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.Magnetic resonance imaging (MRI scan): A special MRI technique (diffusion MRI
Diffusion MRI
Diffusion MRI is a magnetic resonance imaging method that produces in vivo images of biological tissues weighted with the local microstructural characteristics of water diffusion, which is capable of showing connections between brain regions...
) 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
Angiogram
Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins and the heart chambers...
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
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
(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
Craniotomy
A craniotomy is a surgical operation in which a bone flap is temporarily removed from the skull to access the brain. Craniotomies are often a critical operation performed on patients recording, brain imaging, and for neurological manipulations such as electrical stimulation and chemical...
is sometimes done to remove blood, abnormal blood vessels, or a tumor. Medications may be used to reduce swelling, prevent seizure
Seizure
An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...
s, lower blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
, and control pain.
Acute Intraparenchymal Hemorrhage
Clinical History: 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 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
Basal ganglia
The basal ganglia are a group of nuclei of varied origin in the brains of vertebrates that act as a cohesive functional unit. They are situated at the base of the forebrain and are strongly connected with the cerebral cortex, thalamus and other brain areas...
, subcortical white matter, cerebellum, thalamus and pons
Pons
The pons is a structure located on the brain stem, named after the Latin word for "bridge" or the 16th-century Italian anatomist and surgeon Costanzo Varolio . It is superior to the medulla oblongata, inferior to the midbrain, and ventral to the cerebellum. In humans and other bipeds this means it...
. 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 angioma
Cavernous angioma
Cavernous angioma, also known as cerebral cavernous malformation , cavernous haemangioma, and cavernoma, is a vascular disorder that alternately has been classified as neoplastic or hamartomatous. It is characterized by grossly dilated blood vessels with a single layer of endothelium and an...
s 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
Thyroid cancer
Thyroid neoplasm is a neoplasm or tumor of the thyroid. It can be a benign tumor such as thyroid adenoma, or it can be a malignant neoplasm , such as papillary, follicular, medullary or anaplastic thyroid cancer. Most patients are 25 to 65 years of age when first diagnosed; women are more affected...
, renal cell carcinoma
Renal cell carcinoma
Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases...
, melanoma
Melanoma
Melanoma is a malignant tumor of melanocytes. Melanocytes are cells that produce the dark pigment, melanin, which is responsible for the color of skin. They predominantly occur in skin, but are also found in other parts of the body, including the bowel and the eye...
, and lung cancer
Lung cancer
Lung cancer is a disease characterized by uncontrolled cell growth in tissues of the lung. If left untreated, this growth can spread beyond the lung in a process called metastasis into nearby tissue and, eventually, into other parts of the body. Most cancers that start in lung, known as primary...
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.