Intraparenchymal hemorrhage: Difference between revisions

Revision as of 13:48, 19 August 2020

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

Synonyms and keywords:Intracerebral Hemorrhage, Intraparencymal Hematoma, Intracerebral Hematoma, Parenchymal Hemorrhages, Cerebral Brain Hemorrhages; Hemorrhage, Cerebral Brain Hemorrhage, Cerebral Hemorrhage, Cerebrum Parenchymal Hemorrhage, Cerebral Hemorrhages, Cerebrum Hemorrhages;, Cerebral Hemorrhages.

Overview

[Intraparenchymal hemorrhage] is one of the common causes of [stroke]. Although less prevalent than ischemia, intraparenchymal hemorrhage has the highest mortality rate among all the causes of stroke. It is associated with multiple risk factors, with hypertension being the most common among them. Owing to its poor prognosis, early diagnosis and management are of paradigm importance.

Classification

[Intraparenchymal hemorrhage] may be classified according to etiology into [primary] and [secondary intraparenchymal hemorrhage]. Intraparenchymal hemorrhage occurring as a consequence of [hypertension] or [cerebral amyloid angiopathy] is termed as [primary intraparenchymal hemorrhage]. If the etiology is other than [hypertension] or [cerebral amyloid angiopathy] then intraparenchymal hemorrhage is termed as [secondary intraparenchymal hemorrhage].^[1]

Pathophysiology

[Intraparenchymal hemorrhages] are caused by small bleeds that occur when parenchymal arterioles rupture. [Hypertension] is the major risk factor for development of intraparenchymal hemorrhage. [Hypertension] increases the risk of intraparenchymal hemorrhage by inducing certain degenerative changes in small arterioles. Sometimes [aneurysms] form as a consequence and eventually rupture. Hypertensive hemorrhages usually occur in deep brain structures like [basal ganglia], [pons], [thalamus] and [cerebellum].^[2]^[3]^[4]

[Cerebral amyloid angiopathy] is another risk factor that contributes to a large number of [intraparenchymal hemorrhages]. It involves deposition of [ẞ-amyloid] in cortical blood vessels, which results in weakened blood vessels and hence increased risk of rupture. ^[5]

Certain [vascular malformations] are also at increased risk of [rupture] and causing [intraparenchymal hemorrhage]. [Arteriovenous malformations] consist of dysplastic arteries that form a web and drain into veins. These [Av malformations] may rupture leading to intraparenchymal hemorrhage.^[6]
Dural arteriovenous fistulae are abnormal connections between arteries and veins inside [dura matter]. If the drainage occurs into a pressurized vein then there is an increased chance of hemorrhage as a result of [venous hypertension].^[7]

[Cerebral venous thrombosis] may lead to intraparenchymal hemorrhage as there is poor cerebral venous drainage causing increased pressure in vein and eventually venous rupture.^[8]^[9]
*[Saccular aneurysm] when ruptures may lead to intraparenchymal hemorrhage, although it mostly results in [subarachnoid hemorrhage]. [Moyamoya disease] involves the narrowing of intracranial arteries. Collateral blood vessels form as a consequence. These collaterals have fragile walls and are prone to rupture leading to intraparenchymal hemorrhage.^[10]

Causes

The most common cause of [spontaneous intra parenchymal hemorrhage] is [hypertensive angiopathy]. In older adults, most common cause of lobar intra-parenchymal hemorrhage is [cerebral amyloid angiopathy]. For intra-parenchymal hemorrhages in children, [vascular malformations] are the most common cause. Less common causes of [spontaneous intra-parenchymal hemorrhage] include [vasculitis], [CNS infection], [rupture of dural AV fistula], [septic embolism], [mycotic aneurysm rupture], [tumors], [Av malformation rupture], [cerebral hyperperfusion syndrome], [rupture of saccular aneursym], [dural sinus thrombosis], [moyamoya disease], [reversible cerebral vasoconstriction syndromes], [transformation of ischemic stroke into hemorrhagic], [bleeding disorders], [systemic illnesses like cirrhosis of liver and thrombocytopenia], [medications for anticoagulation], [drugs like amphetamines and cocaine]. ^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]

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Differentiating intraparenchymal hemorrhage from other Diseases

[Intraparenchymal hemorrhage] must be differentiated from [ischemic stroke]. But it is difficult to differentiate between the 2 based on clinical features. Therefore, neuroimaging should always be used to confirm the diagnosis.

Epidemiology and Demographics

The incidence of [intra-parenchymal hemorrhage] is approximately [24.6] per 100,000 person years. ^[19]

Age

[Intraparenchymal hemorrhage] is more commonly observed among elderly patients. Risk doubles every 10 years after 35 years of age. ^[20]

Gender

[Intraparenchymal hemorrhage] affects men and women equally. ^[19]

Race

[Intraparenchymal hemorrhage usually affects individuals of [asian] race more than other races.

Risk Factors

The most potent risk factor in the development of [intraparenchymal hemorrhage] is [hypertension]. ^[4] Other risk factors include presence of amyloid angiopathy, old age, use of anti-coagulants, [alcohol intake], [smoking], [low LDL and total cholesterol], [increased HDL cholesterol], [presence of apolipoprotein E with E2 and E4 alleles].

Natural History, Complications, and Prognosis

Common complications of [intraparenchymal hemorrhage] include [raised ICP], [seizures], focal neurologic deficits, [functional decline of patients], [post hemorrhage dementia], [post hemorrhage depression]. ^[21]^[22]^[23]

Prognosis of [intraparenchymal hemorrhage] is generally poor. 30 day [case fatality rate] of IPH is reported to be around 40%.^[19] IPH has the highest [mortality rate] among all the causes of stroke with the [1-year and 10-year survival rates[ of 40% and 24% respectively. ^[24] Annually, it is responsible for over 20,000 deaths in US.

Diagnosis

History and symptoms

Common symptoms of [intraparenchymal hemorrhage] include:^[9]^[16]

[acute onset focal neurological deficit]
[altered sensorium]
[vomiting]
[headache]
[seizures].
[Nausea], [vomiting], [headache] and [decreased level of consciousness] when present point more towards hemorrhage rather than [ischemic stroke]. ^[16] [Seizures] occur more commonly in IPH secondary to [venous sinus thrombosis] or [cavernous malformation] as compared to other causes of IPH. ^[9] Secondary IPH, specially due to [venous sinus thrombosis] and [vascular malformations] usually presents at younger age and patients usually have no history of [hypertension].

Physical examination

Physical examination may be remarkable for:^[25]. A substantial proportion of patients with intraparenchymal hemorrhage have lower than normal GCS. ^[26]^[16] ^[27]

[lower than normal GCS]
[hemiplegia]
[hemisensory loss]
[brady or tachycardia]
[gaze palsy]
[dysarthria]
[facial palsy]
[Dysphasia]

CT scan

[Non-contrast Ct scan] is the gold standard for diagnosing intra parenchymal hemorrhage in [Emergency], as it is readily available and highly sensitive for intra parenchymal hemorrhage. Moreover, it can provide valuable information regarding location and extension of [intra-parenchymal hemorrhage], [hydrocephalus] and [compression of the brainstem by hematoma].^[28]^[29]

[CT angiography] is a very useful technique for identifying vascular abnormalities like [Av shunts], [aneurysms], and [venous sinus thrombosis] that could have lead to intraparenchymal hemorrhage. Though [Ct angiography] is very helpful for diagnosing [vascular malformations] but [digital subtraction angiography] is the [gold standard] for this purpose.^[29] The presence of ["spot sign"] on CTA, i.e, extravasation of contrast within hematoma predicts hematoma expansion and adverse outcome.^[30]

MRI

Owing to its high [sensitivity] and [specificity], MRI is another suitable modality for diagnosis of intraparenchymal hemorrhage. Secondary causes of intraparenchymal hemorrhage like [tumor], [ischemic stroke] or [cavernous malformation] can be better identified by MRI. [Microbleed patterns] indicative of [hypertensive angiopathy] or [cerebral amyloid angiopathy] may also be detected in a better fashion through MRI.^[31]

Electrocardiogram

Findings on ECG associated with intraparenchymal hemorrhage include, [ST-T wave] changes and prolonged [QT interval]. It is suspected to be caused by excess [catecholamine] release as a consequence of brain injury. ^[32]

Echocardiography

Findings on electrocardiography associated with intraparnechymal hemorrhage include, decreased [ejection fraction] and [wall motion abnormalities]. ^[32]

Treatment

Medical Therapy

[Intraparenchymal hemorrhage] is a medical emergency and requires prompt treatment.^[33] ^[34]^[35]^[36]^[37]^[38]^[39] Special attention should be given to [airway support] as these patients may be unable to protect their airways. [Blood pressure] control is an important feature of IPH management as raised blood pressure is associated with hematoma expansion and poor outcome. According to American Heart Association/American Stroke Association guidelines, for IPH patients presenting with [systolic blood pressure] of 150 to 220mmHg, the goal should be to keep the systolic blood pressure below 140mmHg if there is no contraindication. Short acting [anti hypertensives] like [nicardipine] and [labetalol] are recommended while drugs like [nitrates] and [hydralazine] should not be used.

Specific [coagulation factor therapy] or [platelet transfusion] is recommended for patients with [coagulation factor deficiency] or [thrombocytopenia] respectively. [Platelet transfusion] is not recommended for patients on [antiplatelet drugs]. Patients who are taking [warfarin] or any other [Vitamin K antagonist] and have high [INR] should be given [Vitamin K] and [prothrombin complex concentrate].^[25] Idarucizumab should be administered to patients on dabigatran while adexanet alfa should be given to patients taking factor Xa inhibitors. . For reversal of heparin induced coagulopathy, protamine sulphate should be administered.

[Antiepileptics] should be given to patients who present with seizures. Prophylactic use of [antiepileptic] is not recommended. ^[25][Intermittent pneumatic compression] for [Dvt prophylaxis] should also be done. 1 day after the bleeding cessation, [low molecular weight heparin] or [subcutaneous heparin] can also be used for Dvt prophylaxis.

Surgery

Urgent neurosurgical assessment of IPH patients should be done. IPH patients who are [comatose], have substantial [intraventricular hemorrhage] and [hydrocephalus] should undergo [external ventricular drain placement]. ^[25] Benefit of surgical evacuation of hematomas over conservative management is still unproven. Surgical evacuation of hematomas is recommended in case of [cerebellar hematomas] with evidence of [hydrocephalus] or/and [brainstem compression]. ^[25]

Prevention

Long term [blood pressure control] is the most important measure in preventing recurrent [intraparenchymal hemorrhage]. Target blood pressure of less than 130/80mmHg is recommended. In addition to blood pressure control certain other measures like [smoking cessation], [avoiding illicit drug use] as well as [alcohol intake] can have beneficial effects in this regard.

References

↑ Gross BA, Jankowitz BT, Friedlander RM (2019). "Cerebral Intraparenchymal Hemorrhage: A Review". JAMA. 321 (13): 1295–1303. doi:10.1001/jama.2019.2413. PMID 30938800.
↑ Ziai WC, Carhuapoma JR (2018). "Intracerebral Hemorrhage". Continuum (Minneap Minn). 24 (6): 1603–1622. doi:10.1212/CON.0000000000000672. PMID 30516598.
↑ Dye JA, Rees G, Yang I, Vespa PM, Martin NA, Vinters HV (2014). "Neuropathologic analysis of hematomas evacuated from patients with spontaneous intracerebral hemorrhage". Neuropathology. 34 (3): 253–60. doi:10.1111/neup.12089. PMID 24354628.
↑ ^4.0 ^4.1 O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P; et al. (2010). "Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study". Lancet. 376 (9735): 112–23. doi:10.1016/S0140-6736(10)60834-3. PMID 20561675.
↑ Greenberg SM, Charidimou A (2018). "Diagnosis of Cerebral Amyloid Angiopathy: Evolution of the Boston Criteria". Stroke. 49 (2): 491–497. doi:10.1161/STROKEAHA.117.016990. PMC 5892842. PMID 29335334.
↑ Gross BA, Du R (2013). "Natural history of cerebral arteriovenous malformations: a meta-analysis". J Neurosurg. 118 (2): 437–43. doi:10.3171/2012.10.JNS121280. PMID 23198804.
↑ Gross BA, Albuquerque FC, McDougall CG, Jankowitz BT, Jadhav AP, Jovin TG; et al. (2018). "A multi-institutional analysis of the untreated course of cerebral dural arteriovenous fistulas". J Neurosurg. 129 (5): 1114–1119. doi:10.3171/2017.6.JNS171090. PMID 29243979.
↑ Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M; et al. (2011). "Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 42 (4): 1158–92. doi:10.1161/STR.0b013e31820a8364. PMID 21293023.
↑ ^9.0 ^9.1 ^9.2 Lee SK, Mokin M, Hetts SW, Fifi JT, Bousser MG, Fraser JF; et al. (2018). "Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee". J Neurointerv Surg. 10 (8): 803–810. doi:10.1136/neurintsurg-2018-013973. PMID 29871990.
↑ Scott RM, Smith ER (2009). "Moyamoya disease and moyamoya syndrome". N Engl J Med. 360 (12): 1226–37. doi:10.1056/NEJMra0804622. PMID 19297575.
↑ Cordonnier C, Demchuk A, Ziai W, Anderson CS (2018). "Intracerebral haemorrhage: current approaches to acute management". Lancet. 392 (10154): 1257–1268. doi:10.1016/S0140-6736(18)31878-6. PMID 30319113.
↑ Beslow LA, Licht DJ, Smith SE, Storm PB, Heuer GG, Zimmerman RA; et al. (2010). "Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study". Stroke. 41 (2): 313–8. doi:10.1161/STROKEAHA.109.568071. PMC 2821039. PMID 20019325.
↑ Cordonnier C, Demchuk A, Ziai W, Anderson CS (2018). "Intracerebral haemorrhage: current approaches to acute management". Lancet. 392 (10154): 1257–1268. doi:10.1016/S0140-6736(18)31878-6. PMID 30319113.
↑ Meretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S; et al. (2012). "SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage". Stroke. 43 (10): 2592–7. doi:10.1161/STROKEAHA.112.661603. PMID 22858729.
↑ 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.
↑ ^16.0 ^16.1 ^16.2 ^16.3 Gross BA, Jankowitz BT, Friedlander RM (2019). "Cerebral Intraparenchymal Hemorrhage: A Review". JAMA. 321 (13): 1295–1303. doi:10.1001/jama.2019.2413. PMID 30938800.
↑ Swor DE, Maas MB, Walia SS, Bissig DP, Liotta EM, Naidech AM; et al. (2019). "Clinical characteristics and outcomes of methamphetamine-associated intracerebral hemorrhage". Neurology. 93 (1): e1–e7. doi:10.1212/WNL.0000000000007666. PMC 6659002 Check |pmc= value (help). PMID 31142634.
↑ Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M, Misra V; et al. (2010). "Intracerebral hemorrhage in cocaine users". Stroke. 41 (4): 680–4. doi:10.1161/STROKEAHA.109.573147. PMC 3412877. PMID 20185779.
↑ ^19.0 ^19.1 ^19.2 van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ (2010). "Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis". Lancet Neurol. 9 (2): 167–76. doi:10.1016/S1474-4422(09)70340-0. PMID 20056489.
↑ Stein M, Misselwitz B, Hamann GF, Scharbrodt W, Schummer DI, Oertel MF (2012). "Intracerebral hemorrhage in the very old: future demographic trends of an aging population". Stroke. 43 (4): 1126–8. doi:10.1161/STROKEAHA.111.644716. PMID 22282880.
↑ Moulin S, Cordonnier C (2015). "Prognosis and Outcome of Intracerebral Haemorrhage". Front Neurol Neurosci. 37: 182–92. doi:10.1159/000437122. PMID 26587771.
↑ Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G (2002). "Seizures after spontaneous supratentorial intracerebral hemorrhage". Epilepsia. 43 (10): 1175–80. doi:10.1046/j.1528-1157.2002.00302.x. PMID 12366733.
↑ Pendlebury ST, Rothwell PM (2009). "Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis". Lancet Neurol. 8 (11): 1006–18. doi:10.1016/S1474-4422(09)70236-4. PMID 19782001.
↑ Sacco S, Marini C, Toni D, Olivieri L, Carolei A (2009). "Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry". Stroke. 40 (2): 394–9. doi:10.1161/STROKEAHA.108.523209. PMID 19038914.
↑ ^25.0 ^25.1 ^25.2 ^25.3 ^25.4 Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.
↑ Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.
↑ Chung CS, Caplan LR, Yamamoto Y, Chang HM, Lee SJ, Song HJ; et al. (2000). "Striatocapsular haemorrhage". Brain. 123 ( Pt 9): 1850–62. doi:10.1093/brain/123.9.1850. PMID 10960049.
↑ Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.
↑ ^29.0 ^29.1 Macellari F, Paciaroni M, Agnelli G, Caso V (2014). "Neuroimaging in intracerebral hemorrhage". Stroke. 45 (3): 903–8. doi:10.1161/STROKEAHA.113.003701. PMID 24425128.
↑ Khosravani H, Mayer SA, Demchuk A, Jahromi BS, Gladstone DJ, Flaherty M; et al. (2013). "Emergency noninvasive angiography for acute intracerebral hemorrhage". AJNR Am J Neuroradiol. 34 (8): 1481–7. doi:10.3174/ajnr.A3296. PMID 23124634.
↑ Macellari F, Paciaroni M, Agnelli G, Caso V (2014). "Neuroimaging in intracerebral hemorrhage". Stroke. 45 (3): 903–8. doi:10.1161/STROKEAHA.113.003701. PMID 24425128.
↑ ^32.0 ^32.1 Pinnamaneni S, Aronow WS, Frishman WH (2017). "Neurocardiac Injury After Cerebral and Subarachnoid Hemorrhages". Cardiol Rev. 25 (2): 89–95. doi:10.1097/CRD.0000000000000112. PMID 27465536.
↑ Qureshi AI, Mendelow AD, Hanley DF (2009). "Intracerebral haemorrhage". Lancet. 373 (9675): 1632–44. doi:10.1016/S0140-6736(09)60371-8. PMC 3138486. PMID 19427958.
↑ Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.
↑ Elijovich L, Patel PV, Hemphill JC (2008). "Intracerebral hemorrhage". Semin Neurol. 28 (5): 657–67. doi:10.1055/s-0028-1105974. PMID 19115172.
↑ Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.
↑ Pollack CV, Reilly PA, van Ryn J, Eikelboom JW, Glund S, Bernstein RA; et al. (2017). "Idarucizumab for Dabigatran Reversal - Full Cohort Analysis". N Engl J Med. 377 (5): 431–441. doi:10.1056/NEJMoa1707278. PMID 28693366.
↑ Connolly SJ, Milling TJ, Eikelboom JW, Gibson CM, Curnutte JT, Gold A; et al. (2016). "Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors". N Engl J Med. 375 (12): 1131–41. doi:10.1056/NEJMoa1607887. PMC 5568772. PMID 27573206.
↑ Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V (2011). "Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies". J Thromb Haemost. 9 (5): 893–8. doi:10.1111/j.1538-7836.2011.04241.x. PMID 21324058.

Template:WikiDoc Sources

[pmid309388002-1] Gross BA, Jankowitz BT, Friedlander RM (2019). "Cerebral Intraparenchymal Hemorrhage: A Review". JAMA. 321 (13): 1295–1303. doi:10.1001/jama.2019.2413. PMID 30938800.

[pmid30516598-2] Ziai WC, Carhuapoma JR (2018). "Intracerebral Hemorrhage". Continuum (Minneap Minn). 24 (6): 1603–1622. doi:10.1212/CON.0000000000000672. PMID 30516598.

[pmid24354628-3] Dye JA, Rees G, Yang I, Vespa PM, Martin NA, Vinters HV (2014). "Neuropathologic analysis of hematomas evacuated from patients with spontaneous intracerebral hemorrhage". Neuropathology. 34 (3): 253–60. doi:10.1111/neup.12089. PMID 24354628.

[pmid20561675-4] 4.0 ^4.1 O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P; et al. (2010). "Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study". Lancet. 376 (9735): 112–23. doi:10.1016/S0140-6736(10)60834-3. PMID 20561675.

[pmid29335334-5] Greenberg SM, Charidimou A (2018). "Diagnosis of Cerebral Amyloid Angiopathy: Evolution of the Boston Criteria". Stroke. 49 (2): 491–497. doi:10.1161/STROKEAHA.117.016990. PMC 5892842. PMID 29335334.

[pmid23198804-6] Gross BA, Du R (2013). "Natural history of cerebral arteriovenous malformations: a meta-analysis". J Neurosurg. 118 (2): 437–43. doi:10.3171/2012.10.JNS121280. PMID 23198804.

[pmid29243979-7] Gross BA, Albuquerque FC, McDougall CG, Jankowitz BT, Jadhav AP, Jovin TG; et al. (2018). "A multi-institutional analysis of the untreated course of cerebral dural arteriovenous fistulas". J Neurosurg. 129 (5): 1114–1119. doi:10.3171/2017.6.JNS171090. PMID 29243979.

[pmid21293023-8] Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M; et al. (2011). "Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 42 (4): 1158–92. doi:10.1161/STR.0b013e31820a8364. PMID 21293023.

[pmid29871990-9] 9.0 ^9.1 ^9.2 Lee SK, Mokin M, Hetts SW, Fifi JT, Bousser MG, Fraser JF; et al. (2018). "Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee". J Neurointerv Surg. 10 (8): 803–810. doi:10.1136/neurintsurg-2018-013973. PMID 29871990.

[pmid19297575-10] Scott RM, Smith ER (2009). "Moyamoya disease and moyamoya syndrome". N Engl J Med. 360 (12): 1226–37. doi:10.1056/NEJMra0804622. PMID 19297575.

[pmid303191133-11] Cordonnier C, Demchuk A, Ziai W, Anderson CS (2018). "Intracerebral haemorrhage: current approaches to acute management". Lancet. 392 (10154): 1257–1268. doi:10.1016/S0140-6736(18)31878-6. PMID 30319113.

[pmid20019325-12] Beslow LA, Licht DJ, Smith SE, Storm PB, Heuer GG, Zimmerman RA; et al. (2010). "Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study". Stroke. 41 (2): 313–8. doi:10.1161/STROKEAHA.109.568071. PMC 2821039. PMID 20019325.

[pmid303191134-13] Cordonnier C, Demchuk A, Ziai W, Anderson CS (2018). "Intracerebral haemorrhage: current approaches to acute management". Lancet. 392 (10154): 1257–1268. doi:10.1016/S0140-6736(18)31878-6. PMID 30319113.

[pmid22858729-14] Meretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S; et al. (2012). "SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage". Stroke. 43 (10): 2592–7. doi:10.1161/STROKEAHA.112.661603. PMID 22858729.

[pmid20581068-15] 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.

[pmid30938800-16] 16.0 ^16.1 ^16.2 ^16.3 Gross BA, Jankowitz BT, Friedlander RM (2019). "Cerebral Intraparenchymal Hemorrhage: A Review". JAMA. 321 (13): 1295–1303. doi:10.1001/jama.2019.2413. PMID 30938800.

[pmid31142634-17] Swor DE, Maas MB, Walia SS, Bissig DP, Liotta EM, Naidech AM; et al. (2019). "Clinical characteristics and outcomes of methamphetamine-associated intracerebral hemorrhage". Neurology. 93 (1): e1–e7. doi:10.1212/WNL.0000000000007666. PMC 6659002 Check |pmc= value (help). PMID 31142634.

[pmid20185779-18] Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M, Misra V; et al. (2010). "Intracerebral hemorrhage in cocaine users". Stroke. 41 (4): 680–4. doi:10.1161/STROKEAHA.109.573147. PMC 3412877. PMID 20185779.

[pmid20056489-19] 19.0 ^19.1 ^19.2 van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ (2010). "Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis". Lancet Neurol. 9 (2): 167–76. doi:10.1016/S1474-4422(09)70340-0. PMID 20056489.

[pmid22282880-20] Stein M, Misselwitz B, Hamann GF, Scharbrodt W, Schummer DI, Oertel MF (2012). "Intracerebral hemorrhage in the very old: future demographic trends of an aging population". Stroke. 43 (4): 1126–8. doi:10.1161/STROKEAHA.111.644716. PMID 22282880.

[pmid26587771-21] Moulin S, Cordonnier C (2015). "Prognosis and Outcome of Intracerebral Haemorrhage". Front Neurol Neurosci. 37: 182–92. doi:10.1159/000437122. PMID 26587771.

[pmid12366733-22] Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G (2002). "Seizures after spontaneous supratentorial intracerebral hemorrhage". Epilepsia. 43 (10): 1175–80. doi:10.1046/j.1528-1157.2002.00302.x. PMID 12366733.

[pmid19782001-23] Pendlebury ST, Rothwell PM (2009). "Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis". Lancet Neurol. 8 (11): 1006–18. doi:10.1016/S1474-4422(09)70236-4. PMID 19782001.

[pmid19038914-24] Sacco S, Marini C, Toni D, Olivieri L, Carolei A (2009). "Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry". Stroke. 40 (2): 394–9. doi:10.1161/STROKEAHA.108.523209. PMID 19038914.

[pmid26022637-25] 25.0 ^25.1 ^25.2 ^25.3 ^25.4 Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

[pmid260226372-26] Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

[pmid10960049-27] Chung CS, Caplan LR, Yamamoto Y, Chang HM, Lee SJ, Song HJ; et al. (2000). "Striatocapsular haemorrhage". Brain. 123 ( Pt 9): 1850–62. doi:10.1093/brain/123.9.1850. PMID 10960049.

[pmid260226373-28] Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

[pmid24425128-29] 29.0 ^29.1 Macellari F, Paciaroni M, Agnelli G, Caso V (2014). "Neuroimaging in intracerebral hemorrhage". Stroke. 45 (3): 903–8. doi:10.1161/STROKEAHA.113.003701. PMID 24425128.

[pmid23124634-30] Khosravani H, Mayer SA, Demchuk A, Jahromi BS, Gladstone DJ, Flaherty M; et al. (2013). "Emergency noninvasive angiography for acute intracerebral hemorrhage". AJNR Am J Neuroradiol. 34 (8): 1481–7. doi:10.3174/ajnr.A3296. PMID 23124634.

[pmid244251282-31] Macellari F, Paciaroni M, Agnelli G, Caso V (2014). "Neuroimaging in intracerebral hemorrhage". Stroke. 45 (3): 903–8. doi:10.1161/STROKEAHA.113.003701. PMID 24425128.

[pmid27465536-32] 32.0 ^32.1 Pinnamaneni S, Aronow WS, Frishman WH (2017). "Neurocardiac Injury After Cerebral and Subarachnoid Hemorrhages". Cardiol Rev. 25 (2): 89–95. doi:10.1097/CRD.0000000000000112. PMID 27465536.

[pmid19427958-33] Qureshi AI, Mendelow AD, Hanley DF (2009). "Intracerebral haemorrhage". Lancet. 373 (9675): 1632–44. doi:10.1016/S0140-6736(09)60371-8. PMC 3138486. PMID 19427958.

[pmid260226374-34] Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

[pmid19115172-35] Elijovich L, Patel PV, Hemphill JC (2008). "Intracerebral hemorrhage". Semin Neurol. 28 (5): 657–67. doi:10.1055/s-0028-1105974. PMID 19115172.

[pmid260226375-36] Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M; et al. (2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

[pmid28693366-37] Pollack CV, Reilly PA, van Ryn J, Eikelboom JW, Glund S, Bernstein RA; et al. (2017). "Idarucizumab for Dabigatran Reversal - Full Cohort Analysis". N Engl J Med. 377 (5): 431–441. doi:10.1056/NEJMoa1707278. PMID 28693366.

[pmid27573206-38] Connolly SJ, Milling TJ, Eikelboom JW, Gibson CM, Curnutte JT, Gold A; et al. (2016). "Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors". N Engl J Med. 375 (12): 1131–41. doi:10.1056/NEJMoa1607887. PMC 5568772. PMID 27573206.

[pmid21324058-39] Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V (2011). "Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies". J Thromb Haemost. 9 (5): 893–8. doi:10.1111/j.1538-7836.2011.04241.x. PMID 21324058.

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@@ Line 21: / Line 21: @@
 *Certain [vascular malformations] are also at increased risk of [rupture] and causing [intraparenchymal hemorrhage]. [Arteriovenous malformations] consist of dysplastic arteries that form a web and drain into veins. These [Av malformations] may rupture leading to intraparenchymal hemorrhage.<ref name="pmid23198804">{{cite journal| author=Gross BA, Du R| title=Natural history of cerebral arteriovenous malformations: a meta-analysis. | journal=J Neurosurg | year= 2013 | volume= 118 | issue= 2 | pages= 437-43 | pmid=23198804 | doi=10.3171/2012.10.JNS121280 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23198804  }} </ref>
-Dural arteriovenous fistulae are abnormal connections between arteries and veins inside [dura matter]. If the drainage occurs into a pressurized vein then there is an increased chance of hemorrhage as a result of [venous hypertension].<ref name="pmid29243979">{{cite journal| author=Gross BA, Albuquerque FC, McDougall CG, Jankowitz BT, Jadhav AP, Jovin TG | display-authors=etal| title=A multi-institutional analysis of the untreated course of cerebral dural arteriovenous fistulas. | journal=J Neurosurg | year= 2018 | volume= 129 | issue= 5 | pages= 1114-1119 | pmid=29243979 | doi=10.3171/2017.6.JNS171090 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29243979  }} </ref>
+*Dural arteriovenous fistulae are abnormal connections between arteries and veins inside [dura matter]. If the drainage occurs into a pressurized vein then there is an increased chance of hemorrhage as a result of [venous hypertension].<ref name="pmid29243979">{{cite journal| author=Gross BA, Albuquerque FC, McDougall CG, Jankowitz BT, Jadhav AP, Jovin TG | display-authors=etal| title=A multi-institutional analysis of the untreated course of cerebral dural arteriovenous fistulas. | journal=J Neurosurg | year= 2018 | volume= 129 | issue= 5 | pages= 1114-1119 | pmid=29243979 | doi=10.3171/2017.6.JNS171090 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29243979  }} </ref>
 *[Cerebral venous thrombosis] may lead to intraparenchymal hemorrhage as there is poor cerebral venous drainage causing increased pressure in vein and eventually venous rupture.<ref name="pmid21293023">{{cite journal| author=Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M | display-authors=etal| title=Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2011 | volume= 42 | issue= 4 | pages= 1158-92 | pmid=21293023 | doi=10.1161/STR.0b013e31820a8364 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21293023  }} </ref><ref name="pmid29871990">{{cite journal| author=Lee SK, Mokin M, Hetts SW, Fifi JT, Bousser MG, Fraser JF | display-authors=etal| title=Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. | journal=J Neurointerv Surg | year= 2018 | volume= 10 | issue= 8 | pages= 803-810 | pmid=29871990 | doi=10.1136/neurintsurg-2018-013973 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29871990  }} </ref> <br />*[Saccular aneurysm] when ruptures may lead to intraparenchymal hemorrhage, although it mostly results in [subarachnoid hemorrhage]. [Moyamoya disease] involves the narrowing of intracranial arteries. Collateral blood vessels form as a consequence. These collaterals have fragile walls and are prone to rupture leading to intraparenchymal hemorrhage.<ref name="pmid19297575">{{cite journal| author=Scott RM, Smith ER| title=Moyamoya disease and moyamoya syndrome. | journal=N Engl J Med | year= 2009 | volume= 360 | issue= 12 | pages= 1226-37 | pmid=19297575 | doi=10.1056/NEJMra0804622 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19297575  }} </ref>
@@ Line 52: / Line 52: @@
 ==Natural History, Complications, and Prognosis==
-*Common complications of [intraparenchymal hemorrhage] include [raised ICP], [seizures], focal neurologic deficits, [functional decline of patients], [post hemorrhage dementia], [post hemorrhage depression].
+*Common complications of [intraparenchymal hemorrhage] include [raised ICP], [seizures], focal neurologic deficits, [functional decline of patients], [post hemorrhage dementia], [post hemorrhage depression]. <ref name="pmid26587771">{{cite journal| author=Moulin S, Cordonnier C| title=Prognosis and Outcome of Intracerebral Haemorrhage. | journal=Front Neurol Neurosci | year= 2015 | volume= 37 | issue=  | pages= 182-92 | pmid=26587771 | doi=10.1159/000437122 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26587771  }} </ref><ref name="pmid12366733">{{cite journal| author=Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G| title=Seizures after spontaneous supratentorial intracerebral hemorrhage. | journal=Epilepsia | year= 2002 | volume= 43 | issue= 10 | pages= 1175-80 | pmid=12366733 | doi=10.1046/j.1528-1157.2002.00302.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12366733  }} </ref><ref name="pmid19782001">{{cite journal| author=Pendlebury ST, Rothwell PM| title=Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis. | journal=Lancet Neurol | year= 2009 | volume= 8 | issue= 11 | pages= 1006-18 | pmid=19782001 | doi=10.1016/S1474-4422(09)70236-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19782001  }} </ref>
 *Prognosis of [intraparenchymal hemorrhage] is generally poor.  30 day [case fatality rate] of IPH is reported to be around 40%.<ref name="pmid20056489">{{cite journal| author=van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ| title=Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. | journal=Lancet Neurol | year= 2010 | volume= 9 | issue= 2 | pages= 167-76 | pmid=20056489 | doi=10.1016/S1474-4422(09)70340-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20056489  }} </ref> IPH has the highest [mortality rate] among all the causes of stroke with the [1-year and 10-year survival rates[ of 40% and 24% respectively. <ref name="pmid19038914">{{cite journal| author=Sacco S, Marini C, Toni D, Olivieri L, Carolei A| title=Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. | journal=Stroke | year= 2009 | volume= 40 | issue= 2 | pages= 394-9 | pmid=19038914 | doi=10.1161/STROKEAHA.108.523209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038914  }}</ref> Annually, it is responsible for over 20,000 deaths in US.
@@ Line 67: / Line 67: @@
 ===Physical examination===
-Physical examination may be remarkable for:<ref name="pmid30938800">{{cite journal| author=Gross BA, Jankowitz BT, Friedlander RM| title=Cerebral Intraparenchymal Hemorrhage: A Review. | journal=JAMA | year= 2019 | volume= 321 | issue= 13 | pages= 1295-1303 | pmid=30938800 | doi=10.1001/jama.2019.2413 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30938800  }} </ref> <ref name="pmid10960049">{{cite journal| author=Chung CS, Caplan LR, Yamamoto Y, Chang HM, Lee SJ, Song HJ | display-authors=etal| title=Striatocapsular haemorrhage. | journal=Brain | year= 2000 | volume= 123 ( Pt 9) | issue=  | pages= 1850-62 | pmid=10960049 | doi=10.1093/brain/123.9.1850 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10960049  }} </ref>
+Physical examination may be remarkable for:<ref name="pmid26022637">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }}</ref>. A substantial proportion of patients with intraparenchymal hemorrhage have lower than normal GCS. <ref name="pmid260226372">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }}</ref><ref name="pmid30938800">{{cite journal| author=Gross BA, Jankowitz BT, Friedlander RM| title=Cerebral Intraparenchymal Hemorrhage: A Review. | journal=JAMA | year= 2019 | volume= 321 | issue= 13 | pages= 1295-1303 | pmid=30938800 | doi=10.1001/jama.2019.2413 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30938800  }} </ref> <ref name="pmid10960049">{{cite journal| author=Chung CS, Caplan LR, Yamamoto Y, Chang HM, Lee SJ, Song HJ | display-authors=etal| title=Striatocapsular haemorrhage. | journal=Brain | year= 2000 | volume= 123 ( Pt 9) | issue=  | pages= 1850-62 | pmid=10960049 | doi=10.1093/brain/123.9.1850 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10960049  }} </ref>
 *[lower than normal GCS]
 *[hemiplegia]
@@ Line 78: / Line 78: @@
 ===CT scan===
-*[Non-contrast Ct scan] is the gold standard for diagnosing intra parenchymal hemorrhage in [Emergency], as it is readily available and highly sensitive for intra parenchymal hemorrhage. Moreover, it can provide valuable information regarding location and extension of [intra-parenchymal hemorrhage], [hydrocephalus] and [compression of the brainstem by hematoma].
+*[Non-contrast Ct scan] is the gold standard for diagnosing intra parenchymal hemorrhage in [Emergency], as it is readily available and highly sensitive for intra parenchymal hemorrhage. Moreover, it can provide valuable information regarding location and extension of [intra-parenchymal hemorrhage], [hydrocephalus] and [compression of the brainstem by hematoma].<ref name="pmid260226373">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }}</ref><ref name="pmid24425128">{{cite journal| author=Macellari F, Paciaroni M, Agnelli G, Caso V| title=Neuroimaging in intracerebral hemorrhage. | journal=Stroke | year= 2014 | volume= 45 | issue= 3 | pages= 903-8 | pmid=24425128 | doi=10.1161/STROKEAHA.113.003701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24425128  }}</ref>
-*[CT angiography] is a very useful technique for identifying vascular abnormalities like [Av shunts], [aneurysms], and [venous sinus thrombosis] that could have lead to intraparenchymal hemorrhage.  Though [Ct angiography] is very helpful for diagnosing [vascular malformations] but [digital subtraction angiography] is the [gold standard] for this purpose.<ref name="pmid24425128">{{cite journal| author=Macellari F, Paciaroni M, Agnelli G, Caso V| title=Neuroimaging in intracerebral hemorrhage. | journal=Stroke | year= 2014 | volume= 45 | issue= 3 | pages= 903-8 | pmid=24425128 | doi=10.1161/STROKEAHA.113.003701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24425128  }} </ref> The presence of ["spot sign"] on CTA, i.e, extravasation of contrast within hematoma predicts hematoma expansion and adverse outcome.
+*[CT angiography] is a very useful technique for identifying vascular abnormalities like [Av shunts], [aneurysms], and [venous sinus thrombosis] that could have lead to intraparenchymal hemorrhage.  Though [Ct angiography] is very helpful for diagnosing [vascular malformations] but [digital subtraction angiography] is the [gold standard] for this purpose.<ref name="pmid24425128">{{cite journal| author=Macellari F, Paciaroni M, Agnelli G, Caso V| title=Neuroimaging in intracerebral hemorrhage. | journal=Stroke | year= 2014 | volume= 45 | issue= 3 | pages= 903-8 | pmid=24425128 | doi=10.1161/STROKEAHA.113.003701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24425128  }} </ref> The presence of ["spot sign"] on CTA, i.e, extravasation of contrast within hematoma predicts hematoma expansion and adverse outcome.<ref name="pmid23124634">{{cite journal| author=Khosravani H, Mayer SA, Demchuk A, Jahromi BS, Gladstone DJ, Flaherty M | display-authors=etal| title=Emergency noninvasive angiography for acute intracerebral hemorrhage. | journal=AJNR Am J Neuroradiol | year= 2013 | volume= 34 | issue= 8 | pages= 1481-7 | pmid=23124634 | doi=10.3174/ajnr.A3296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23124634  }} </ref>
 ===MRI===
-*Owing to its high [sensitivity] and [specificity], MRI is another suitable modality for diagnosis of intraparenchymal hemorrhage. Secondary causes of intraparenchymal hemorrhage like [tumor], [ischemic stroke] or [cavernous malformation] can be better identified by MRI. [Microbleed patterns] indicative of [hypertensive angiopathy] or [cerebral amyloid angiopathy] may also be detected in a better fashion through MRI.
+*Owing to its high [sensitivity] and [specificity], MRI is another suitable modality for diagnosis of intraparenchymal hemorrhage. Secondary causes of intraparenchymal hemorrhage like [tumor], [ischemic stroke] or [cavernous malformation] can be better identified by MRI. [Microbleed patterns] indicative of [hypertensive angiopathy] or [cerebral amyloid angiopathy] may also be detected in a better fashion through MRI.<ref name="pmid244251282">{{cite journal| author=Macellari F, Paciaroni M, Agnelli G, Caso V| title=Neuroimaging in intracerebral hemorrhage. | journal=Stroke | year= 2014 | volume= 45 | issue= 3 | pages= 903-8 | pmid=24425128 | doi=10.1161/STROKEAHA.113.003701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24425128  }}</ref>
 <br />
@@ Line 96: / Line 96: @@
-*[Intraparenchymal hemorrhage] is a medical emergency and requires prompt treatment. Special attention should be given to [airway support] as these patients may be unable to protect their airways. [Blood pressure] control is an important feature of IPH management as raised blood pressure is associated with hematoma expansion and poor outcome. According to American Heart Association/American Stroke Association guidelines, for IPH patients presenting with [systolic blood pressure] of 150 to 220mmHg, the goal should be to keep the systolic blood pressure below 140mmHg if there is no contraindication.  Short acting [anti hypertensives] like [nicardipine] and [labetalol] are recommended while drugs like [nitrates] and [hydralazine] should not be used.
+*[Intraparenchymal hemorrhage] is a medical emergency and requires prompt treatment.<ref name="pmid19427958">{{cite journal| author=Qureshi AI, Mendelow AD, Hanley DF| title=Intracerebral haemorrhage. | journal=Lancet | year= 2009 | volume= 373 | issue= 9675 | pages= 1632-44 | pmid=19427958 | doi=10.1016/S0140-6736(09)60371-8 | pmc=3138486 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19427958  }}</ref> <ref name="pmid260226374">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }}</ref><ref name="pmid19115172">{{cite journal| author=Elijovich L, Patel PV, Hemphill JC| title=Intracerebral hemorrhage. | journal=Semin Neurol | year= 2008 | volume= 28 | issue= 5 | pages= 657-67 | pmid=19115172 | doi=10.1055/s-0028-1105974 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19115172  }}</ref><ref name="pmid260226375">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }}</ref><ref name="pmid28693366">{{cite journal| author=Pollack CV, Reilly PA, van Ryn J, Eikelboom JW, Glund S, Bernstein RA | display-authors=etal| title=Idarucizumab for Dabigatran Reversal - Full Cohort Analysis. | journal=N Engl J Med | year= 2017 | volume= 377 | issue= 5 | pages= 431-441 | pmid=28693366 | doi=10.1056/NEJMoa1707278 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28693366  }} </ref><ref name="pmid27573206">{{cite journal| author=Connolly SJ, Milling TJ, Eikelboom JW, Gibson CM, Curnutte JT, Gold A | display-authors=etal| title=Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. | journal=N Engl J Med | year= 2016 | volume= 375 | issue= 12 | pages= 1131-41 | pmid=27573206 | doi=10.1056/NEJMoa1607887 | pmc=5568772 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27573206  }} </ref><ref name="pmid21324058">{{cite journal| author=Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V| title=Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies. | journal=J Thromb Haemost | year= 2011 | volume= 9 | issue= 5 | pages= 893-8 | pmid=21324058 | doi=10.1111/j.1538-7836.2011.04241.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21324058  }} </ref> Special attention should be given to [airway support] as these patients may be unable to protect their airways. [Blood pressure] control is an important feature of IPH management as raised blood pressure is associated with hematoma expansion and poor outcome. According to American Heart Association/American Stroke Association guidelines, for IPH patients presenting with [systolic blood pressure] of 150 to 220mmHg, the goal should be to keep the systolic blood pressure below 140mmHg if there is no contraindication.  Short acting [anti hypertensives] like [nicardipine] and [labetalol] are recommended while drugs like [nitrates] and [hydralazine] should not be used.
 *Specific [coagulation factor therapy] or [platelet transfusion] is recommended for patients with [coagulation factor deficiency] or [thrombocytopenia] respectively. [Platelet transfusion] is not recommended for patients on [antiplatelet drugs]. Patients who are taking [warfarin] or any other [Vitamin K antagonist] and have high [INR] should be given [Vitamin K] and [prothrombin complex concentrate].<ref name="pmid26022637">{{cite journal| author=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M | display-authors=etal| title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2015 | volume= 46 | issue= 7 | pages= 2032-60 | pmid=26022637 | doi=10.1161/STR.0000000000000069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022637  }} </ref> Idarucizumab should be administered to patients on dabigatran while adexanet alfa should be given to patients taking factor Xa inhibitors.  . For reversal of heparin induced coagulopathy, protamine sulphate should be administered.