Intracerebral hemorrhage pathophysiology

Jump to navigation Jump to search

Intracerebral hemorrhage Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Stroke from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Emergency Diagnosis and Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

CT

MRI

Other Imaging Findings

Treatment

Early Assessment

Management

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015)

Management of ICH

AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014)

Primary Prevention of Stroke

Case Studies

Case #1

Intracerebral hemorrhage pathophysiology On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Intracerebral hemorrhage pathophysiology

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Intracerebral hemorrhage pathophysiology

CDC on Intracerebral hemorrhage pathophysiology

Intracerebral hemorrhage pathophysiology in the news

Blogs on Intracerebral hemorrhage pathophysiology

Directions to Hospitals Treating Stroke

Risk calculators and risk factors for Intracerebral hemorrhage pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue and usually results from rupture of small penetrating arteries in the brain. Degenerative changes in the vessel wall may be associated with advancing age, chronic HTN, diabetes, and other vascular risk factor and It usually occurs at or near the bifurcation of affected arterioles.[1][2] The exact cause of brain damage following intracerebral hemorrhage is unknown. It is thought that ICH may result in brain injury by decreasing blood flow into the area surrounding the clot and causing neuronal ischemia or by overexertion of matrix metalloproteinases (MMPs), which may result in the breakdown of the blood brain barrier and edema.[3][4][5][6]

Pathophysiology

Spontaneous bleeding into the brain parenchyma results from rupture of small penetrating arteries in the brain. Degenerative changes in the vessel wall may be associated with advancing age, chronic HTN, diabetes, and other vascular risk factor and It usually occurs at or near the bifurcation of affected arterioles.[1][2]

The exact cause of brain damage following intracerebral hemorrhage is unknown. It is thought that ICH may result in brain injury by following mechanisms:[5][6]

Intraparenchymal hemorrhage

  • High blood pressure and aging blood vessels are the most common causes of intracerebral hemorrhage (intraparenchymal hemorrhage). Hyperten­sive Intracerebral hemorrhage (ICH) usually results from spontaneous rupture of a small artery deep in the brain.[7][8] Breaks in the vessel wall usually occurs following chronic hypertension. Prolonged hypertentsion usually result in intimal hyperplasia and hyalinosis, which may result in focal necrosis and cause in vessel wall breaks. Massive hemorrhage may occur when the patients have a bleeding disorder and clotting system is unable to control the bleeding.[9]
  • Intracerebral hemorrhage can also caused by an arteriovenous malformation (AVM). AVM occurs as a result of abnormal connection between arteries and veins in the brain and can result in vessels break and bleed into the brain.

Anatomical locations

The most common sites for hypertensive ICH include:[13][1]

The small arteries in these areas seem more sensitive to hypertension and as a result, it may progress to vascular injury.

If intracerebral hemorrhage (ICH) occurs in other brain areas or in non hypertensive patients, the other causes of intracerebral hemorrhage should be considered such as:[1]

Intraventricular hemorrhage

Intraventricular hemorrhage (IVH) can be:[14][15]

  • Primary, confined to the ventricles
  • Secondary, originating as an extension of an ICH

Most IVH is secondary and related to hypertensive hemorrhages involving the basal ganglia and thalamus.

Microbleeds

It is a clinically silent cerebral microbleeds directly into the brain tissue. It is thought that intimal hyperplasia and hyalinosis following hypertension and amyloid disposition may result in pseudoaneurysm formation and blood vessel leakage.[16][17]

Associated conditions

Anatomical locations

The microbleeds anatomical locations are varies with their etiology:[17]

  • Hypertensive microbleeds
    • Deep subcortical and infratentorial regions
  • Amyloid microbleeds
    • Superficial lobar regions of the cerebral hemispheres

Gross pathology

The following are images associated with gross pathology of cerebral hemorrhage:

References

  1. 1.0 1.1 1.2 1.3 Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF (2001). "Spontaneous intracerebral hemorrhage". N Engl J Med. 344 (19): 1450–60. doi:10.1056/NEJM200105103441907. PMID 11346811.
  2. 2.0 2.1 Fisher CM (1971). "Pathological observations in hypertensive cerebral hemorrhage". J Neuropathol Exp Neurol. 30 (3): 536–50. PMID 4105427.
  3. 5.0 5.1 Lee KR, Kawai N, Kim S, Sagher O, Hoff JT (1997). "Mechanisms of edema formation after intracerebral hemorrhage: effects of thrombin on cerebral blood flow, blood-brain barrier permeability, and cell survival in a rat model". J Neurosurg. 86 (2): 272–8. doi:10.3171/jns.1997.86.2.0272. PMID 9010429.
  4. 6.0 6.1 Mendelow AD (1993). "Mechanisms of ischemic brain damage with intracerebral hemorrhage". Stroke. 24 (12 Suppl): I115–7, discussion I118-9. PMID 8249006.
  5. Folsom AR, Yatsuya H, Mosley TH, Psaty BM, Longstreth WT (2012). "Risk of intraparenchymal hemorrhage with magnetic resonance imaging-defined leukoaraiosis and brain infarcts". Ann Neurol. 71 (4): 552–9. doi:10.1002/ana.22690. PMC 3377969. PMID 22522444.
  6. Delgado Almandoz JE, Schaefer PW, Goldstein JN, Rosand J, Lev MH, González RG; et al. (2010). "Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score". AJNR Am J Neuroradiol. 31 (9): 1653–60. doi:10.3174/ajnr.A2156. PMC 3682824. PMID 20581068.
  7. Garcia JH, Ho KL (1992). "Pathology of hypertensive arteriopathy". Neurosurg Clin N Am. 3 (3): 497–507. PMID 1633473.
  8. Nicoll JA, Burnett C, Love S, Graham DI, Dewar D, Ironside JW; et al. (1997). "High frequency of apolipoprotein E epsilon 2 allele in hemorrhage due to cerebral amyloid angiopathy". Ann Neurol. 41 (6): 716–21. doi:10.1002/ana.410410607. PMID 9189032.
  9. Passero S, Burgalassi L, D'Andrea P, Battistini N (1995). "Recurrence of bleeding in patients with primary intracerebral hemorrhage". Stroke. 26 (7): 1189–92. PMID 7604411.
  10. Neau JP, Ingrand P, Couderq C, Rosier MP, Bailbe M, Dumas P; et al. (1997). "Recurrent intracerebral hemorrhage". Neurology. 49 (1): 106–13. PMID 9222177.
  11. Cordonnier C, Klijn CJ, van Beijnum J, Al-Shahi Salman R (2010). "Radiological investigation of spontaneous intracerebral hemorrhage: systematic review and trinational survey". Stroke. 41 (4): 685–90. doi:10.1161/STROKEAHA.109.572495. PMID 20167915.
  12. Engelhard HH, Andrews CO, Slavin KV, Charbel FT. Current manage- ment of intraventricular hemorrhage. Surg Neurol. 2003;60:15–21.
  13. Huttner HB, Hartmann M, Köhrmann M, Neher M, Stippich C, Hähnel S, Kress B. Repeated digital substraction angiography after perimesencephalic subarachnoid hemorrhage? J Neuroradiol. 2006;33:87–89.
  14. Altmann-Schneider I, Trompet S, de Craen AJ, van Es AC, Jukema JW, Stott DJ; et al. (2011). "Cerebral microbleeds are predictive of mortality in the elderly". Stroke. 42 (3): 638–44. doi:10.1161/STROKEAHA.110.595611. PMID 21233474.
  15. 17.0 17.1 Liu W, Liu R, Sun W, Peng Q, Zhang W, Xu E; et al. (2012). "Different impacts of blood pressure variability on the progression of cerebral microbleeds and white matter lesions". Stroke. 43 (11): 2916–22. doi:10.1161/STROKEAHA.112.658369. PMID 22949472.
  16. Poels MM, Ikram MA, van der Lugt A, Hofman A, Krestin GP, Breteler MM; et al. (2011). "Incidence of cerebral microbleeds in the general population: the Rotterdam Scan Study". Stroke. 42 (3): 656–61. doi:10.1161/STROKEAHA.110.607184. PMID 21307170.
  17. Klarenbeek P, van Oostenbrugge RJ, Rouhl RP, Knottnerus IL, Staals J (2013). "Higher ambulatory blood pressure relates to new cerebral microbleeds: 2-year follow-up study in lacunar stroke patients". Stroke. 44 (4): 978–83. doi:10.1161/STROKEAHA.111.676619. PMID 23449261.
  18. Goos JD, Henneman WJ, Sluimer JD, Vrenken H, Sluimer IC, Barkhof F; et al. (2010). "Incidence of cerebral microbleeds: a longitudinal study in a memory clinic population". Neurology. 74 (24): 1954–60. doi:10.1212/WNL.0b013e3181e396ea. PMID 20548041.
  19. Jeerakathil T, Wolf PA, Beiser A, Hald JK, Au R, Kase CS; et al. (2004). "Cerebral microbleeds: prevalence and associations with cardiovascular risk factors in the Framingham Study". Stroke. 35 (8): 1831–5. doi:10.1161/01.STR.0000131809.35202.1b. PMID 15155954.


Template:WS Template:WH