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Intraparenchymal / Intraventricular Hemorrhage

Last modified by Hussein Abdallah on 2025/04/21 05:30

 

FACTS

Usually hypertensive, get ready for an EVD if mental status poor

Etiologies: 

Most common

  • Hypertensive (most common) usually in basal ganglia, thalamus, pons, cerebellum
  • Amyloid bleeds (lobar)

Less common

  • arteriovenous malformation (anywhere but usually superficial/lobar)
  • neoplasms, most commonly metastatic melanona, choriocarcinoma, oligodendroglioma, any glioma 
  • venous thrombosis (parasagittal) 
  • blood dyscrasias/fat emboli (scattered petechial) 

CONSULT

HPI 

  • What was systolic blood pressure on arrival? 
  • Medical history
    • AC/AP use 
    • Known HTN? adherent to home meds? 
    • Prior MI / stroke 
    • smoker
    • amyloid angiopathy or bleeding diathesis in patient or family 
    • any cancer history
  • Social history
    • cocaine/amphetamine user 
  • Review of systems
    • did the patient seize 
    • Hydro symptoms: 
      • drowsy / vomiting 
  • Calculate ICH score

FOCUSED EXAM

mental status is most important. Calculate GCS for the ICH score 

IMG 

[ ] CTH 
[ ] MRI Brain w/o can show multiple amyloid bleeds not seen on dry CT 

A/P

[ ] Admit to neuro-ICU (stroke if no EVD, NSGY if EVD)
[ ] Stroke consult 
[ ] Reverse AP/AC 
[ ] EVD pending mental status, no official scale but can basically use hunt hess, will be attending dependent  
[ ] CAP 140
[ ] HOB > 30 
[ ] Keppra usually only if seized (no prophylactic unless blood burden massive) 
[ ] 6 hour dry stability scan (make sure dual energy if received contrast)
[ ] MRI Brain w/wo to rule out lesion, this is not a priority and should only be done once stability of bleed established on ≥ 6 hr dry CT and if patient is stable enough for transport / lying flat for 20-30 minutes 
[ ] +/- DSA (can also be an AVM)

Trials for catheter based clot evacuation

TBA: CLEAR I, II, III (IVH) or MISTIE I, II, III (ICH)

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If lobar locaation of bleed, most likely amyloid angiopathy