Intraparenchymal Hemorrhage, Extradural Hemorrhage & Subdural Hemorrhage

Intraparenchymal Bleeding 

Bleeding into the brain parenchyma proper is referred to as Intraparenchymal hemorrhage.

Case Scenario

A 50 year old, HTN (non-compliant with medications) comes with the chief C/O → Facial asymmetry and sudden onset →  Aphasia and weakness in right arm/shoulder 

Provisional diagnosis – LMCA Territory stroke O/E → DTR are Brisk and Babinski sign (+). Non-cooperative with Fundus examination

• Door to CT scan time <20 min

• Hyper density/Obstructive 
• I.P.H/Hydrocephalus 

Rx

• Control of HTN Crisis :> 220/130 – IV Nicardipine
• Control of Raised ICP → Ventriculostomy 

↓ Fails 

Decompressive Hemicraniectomy 

• Warfarin ++ → I.P.H.

Rx

• Prothrombin complex concentrate is superior to FFP in warfarin induced Hemorrhage. 

Extradural Hemorrhage

• Middle meningeal artery is the source bleeding 
• NCCT heads shows lenticular hyperdensity 
• Mass effect of CNS bleed leads to obstructive Hydrocephalus
• Lucid interval [consciousness between 2 periods of unconsciousness] may be present. 

Rx of EDH with Posturing

• Burr hole 
• Decompressive Hemicraniectomy. 

Decision for which side to Perform Burr hole is based on

• CT Scan Report 
• I/L mid dilated pupil, sluggish  ® to reaction
• On the left side if pupils are equivocal in response to light.

SDH- Subdural hemorrhage

• Source of bleeding: Cortical bridging veins

Clinical scenario

70 yr male → Obese, T2 DM, Slipped in Bathroom 7 days back → Bump on head (Subperiosteal Bleeding) + C/O Focal deficit and Arm weakness.

• People prone to SDH → Stunt actor/ Boxer/ Mixed martial arts

• Parkinsonian patient
• Diabetic neuropathy patients

• Acute SDH shows → Concavo-convex hyperdensity 
• Chronic SDH shows → After 2-3 weeks hypodensity is there - Black pockets in white blood collection are there due to reabsorption of the blood.

Important Information 

• Festinating gait. Sensory ataxia later on gradual onset of neurological symptoms. O/E: Fundus shows Papilledema - DTR are Brisk and Babinski sign is elicited. This is the typical history given in exams regarding the chronic SDH.

Rx

• The Sx intervention in these cases is not required in all cases and is dependable on ICH score:

ICH Score components

• Age
• GCS
• Volume of bleed
• Location of bleed

Important Information
●   If the patient is >75 yr old and GCS is < 8. volume of bleed > 30 cc and is infratentorial bleed then in these worst scenarios the requirement of Sx intervention is must for management of the patient.

• Decompressive Hemicraniectomy
  • In other cases where the patient does not have the components mentioned above and got mild neurological deficit then the patient is managed conservatively by:-
  • ORAL Glycerol
  • Acetazolamide

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