Intracranial Hemorrhage

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Spontaneous intracranial haemorrhage accounts for about 15% of all strokes.

Cerebral haematomas are most commonly caused by hypertensive vascular damage

The most common cause of cerebral haemorrhage is hypertensive vascular damage. Prolonged hypertension results in arteriosclerosis and in the development of small microaneurysms (Charcot-Bouchard aneurysms), which predispose to vessel rupture, resulting in a haematoma. The common sites for hypertensive intracerebral haematoma are those supplied by fine perforating vessels (basal ganglia, internal capsule, thalamus, cerebellum and pons).

In patients over the age of 70 years, 10% of cerebral haemorrhages are caused by the presence of cerebral artery amyloid, which is composed of b(A4) protein. This causes haematomas, seen in the periphery of cerebral hemispheres (lobar haemorrhages). This type is associated with a better clinical outcome than the deep bleeds associated with hypertension.

Less common causes of a cerebral haematoma are bleeding into a tumour, rupture of vascular malformations, cerebral vasculitis, bleeding associated with disordered coagulation, and bleeding occurring in association with leukaemias.

Macroscopically, haematomas appear as a large blood clot, causing compression and damage to adjacent brain. Large haematomas in the basal ganglia or thalamus often rupture into the ventricular system. If the patient survives a bleed, the haematoma is removed by phagocytic cells; astrocytic gliosis takes place, leaving a cavity stained yellow-brown with haemosiderin.

Large bleeds that cause raised intracranial pressure, and those that rupture into the ventricular system, are usually fatal.

Sub-arachnoid haemorrhage is most often caused by a ruptured berry aneurysm

Bleeding into the sub-arachnoid space (between the arachnoid and the pia) is termed sub-arachnoid haemorrhage. A cause of stroke from adolescence to old age, it accounts for about 5% of all cases. In most cases, the cause of sub-arachnoid bleeding is rupture of a berry aneurysm; less common causes are rupture of an intracerebral haematoma into the sub-arachnoid space or rupture 
of a vascular malformation.

Macroscopically a layer of blood is present over the brain surface in the sub-arachnoid space. Blood is therefore present in the cerebrospinal fluid (CSF) and can be detected on lumbar puncture. There are two effects of sub-arachnoid haemorrhage:

1 Blood around vessels causes vascular spasm and leads to widespread cerebral ischaemia and brain swelling.

2 There may be blockage of CSF resorption, causing acute hydrocephalus.

About 30% of patients die immediately; others who present with headache and signs of meningeal irritation may have surgical intervention and clipping of the aneurysm. In the absence of operative intervention, 30% of patients have a re-bleed within one year, most within one month of their first bleed. A long-term complication is development of hydrocephalus caused by blockage and fibrosis in the CSF pathways.
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