Neurology | Parenchymal Hemorrhage

Hi everyone, welcome back to the MedBullet Step 2 and 3 podcast. In today's episode, we covered the topic of perincomal hemorrhage found under the neurology section at medbullets.com. Let's begin with the clinical snapshot. A 61-year-old man presents to the emergency department after his son found him somnolent at home on the floor. The son is not sure how this event occurred. Medical history is significant for hypertension, Alzheimer's dementia, and atrial fibrillation. He is currently taking Lysinopril, Mentoprolol, Donepizil, and Warfarin. A CT head without contrast is performed and demonstrates a cerebellar bleed. The bed is elevated, he has given Manitol and intravenous vitamin K and fresh frozen plasma. Neurosurgery is consulted for emergent cerebellar decompression. Let's continue with an introduction to perincomal hemorrhage. Clinically, it is defined as bleeding within the brain perincoma. Risk factors include hypertension, which is the most common risk factor, and cerebral amyloid angiopathy, which is the second most common. In terms of the pathogenesis, there may be hypertension vasculopathy. This refers to chronic hypertension leading to blood vessel wall thickening, which then leads to blood vessel rupture. It may also be from a sharkaboo shard aneurysm, which leads to an intraperincomal bleed. This ultimately results in a basal ganglia bleed, most commonly in the putamen. Other possible locations include the thalamus, cerebellum, low bar bleeds, and the ponds. Another possible mechanism is due to amyloid angiopathy. This refers to beta amyloid deposits in the vessel walls, which lead to blood vessel wall thickening, and this ultimately results in a low bar bleed. Moving on to the presentation. Symptoms and physical exam findings will depend on the location of the bleed. There may be a headache, nausea vomiting, and impaired consciousness in large bleeds. This may include lethargy, headache, and uptendation. One may also note contralateral limb weakness in putamenal bleeds, or contralateral sensory deficits in thalamic bleeds. In terms of further imaging, a CT head without contrast is indicated as the initial imaging study in patients with changes in cognition and neurological deficits. Specific findings may include basal ganglia bleed seen in hypertensive vasculopathy, or low bar bleed seen in amyloid angiopathy. In terms of further studies, one can evaluate coagulation studies with a PTT and INR. Other studies may include cardiopulmonary monitoring, intracranial pressure monitoring in altered patients, and an electroencephalogram. In terms of the differential, make sure to think about a migraine headache, with differentiating factors being that this will present neurological deficits typically associated with the headache. Also consider an epidural hematoma, with differentiating factors being that this may present with a convex hyperdensity that does not surpass the suture lines on head CT without contrast. In terms of treatment, medical options include mannitol or hypertonic saline. This is indicated as it effectively decreases intracranial pressure. Another option is anti-apoleptic drugs. This is indicated to treat seizures. And another medical option is reversal of anticoagulation. This is used in patients who are on anticoagulation, such as warfarin. Specific medications that may be used include vitamin K and fresh frozen plasma, which is used to reverse warfarin, or protamine sulfate, which is used to reverse heparin. Operative options include cerebellar decompression. This is indicated in patients with a cerebellar hemorrhage. Remember that the cerebellum is located in a tight compartment, which places the patient at risk for cerebral herniation and death. Another option is open craniotomy. This is indicated in patients with a supratentorial hemorrhage. And lastly, complications related to perencomal hemorrhage include cerebral herniation, seizures, and intraventricular bleeding. Now that we've discussed the major points relating to perencomal hemorrhage, let's walk through some questions to apply what we've learned and get a sense of how the topic might be tested. For the first question, consider the following clinical scenario. An 82-year-old man presents to the emergency department for a change in his mental status. The patient was found sitting in his chair after dinner and was difficult to arouse. He seemed to have difficulty with simple tasks and walking, so the patient's wife brought him to the emergency department. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. His current medications include a torvestatin, lysineapril, insulin, and metformin. His temperature is 99.5 degrees Fahrenheit or 37.5 degrees Celsius. Blood pressure is 177 over 99, pulse is 90 beats per minute, respirations are 17 breaths per minute, and oxygen saturation is 98 percent on room air. Neurologic exam is deferred due to the patient's condition. A CT scan is performed, which demonstrates hyperdense collections of blood within the lobes of the brain. Which of the following is the most likely cause of this patient's presentation? And the answer choices are, choice 1, vessel embolization, choice 2, small penetrating artery block, choice 3, bridging vein injury, choice 4, ruptured vessel aneurysm, or choice 5, deposition of beta amyloid and blood vessel walls. The best answer to this question is, choice 5, deposition of beta amyloid and blood vessel walls. This patient is presenting with a change in mental status and a CT scan demonstrating a low bar hemorrhage. Low bar hemorrhages typically occur secondary to deposition of beta amyloid and blood vessel walls. Any patient who is elderly and presents with altered mental status, particularly in the setting of focal neurological findings, should receive a head CT. In a low bar hemorrhage, one can see hyperdense collections of blood located superficially within the lobes of the brain. The most common cause of a low bar hemorrhage is deposition of beta amyloid in the blood vessel walls, which can weaken the vessels and predispose to a rupture. Let's also discuss why the other choices are incorrect. Choice 1, vessel embolization describes an ischemic stroke. An ischemic stroke would not present with hyperdense collections of blood on head CT. Choice 2, small penetrating artery block describes a lacunar stroke. Lacunar stroke presents with small discrete foci of hypodensity on CT scan. Choice 3, bridging vein injury describes a subdural hematoma. A subdural hematoma presents with a crescent-shaped hyperdense lesion on head CT. Choice 4, ruptured vessel aneurysm describes a charco-bouchard aneurysm that has ruptured. Typically, lesions on head CT will be seen in the basal ganglia rather than the lobes of the brain. Finally, a bullet summary. The most common cause of low bar hemorrhage in the elderly is deposition of beta amyloid in blood vessel walls. For the second question, consider the following clinical scenario. A 67-year-old man presents to the emergency department with altered mental status. The patient was found confused in his retirement home and was then brought to the emergency department by emergency medical services. His temperature is 99.3 degrees Fahrenheit or 37.4 degrees Celsius. Pulse is 115 beats per minute, respirations are 13 breaths per minute, and oxygen saturation is 98% on room air. The patient is started on IV fluids. A head CT is obtained which demonstrates an intraparenchymal brain hemorrhage. Which of the following is most likely to be true for this patient? And the answer choices are Choice 1, a history of alcohol abuse. Choice 2, a recent fall causing sudden head trauma. Choice 3, chronic steady bleeding into the brain. Choice 4, deposition of plaques in the central nervous system. Or Choice 5, poorly managed hypertension. The best answer to this question is Choice 5, poorly managed hypertension. This patient is presenting with altered mental status and a head CT suggestive of a diagnosis of intraparenchymal hemorrhage. The greatest risk factor for this pathology is poorly controlled hypertension. Intraparenchymal brain hemorrhage presents with altered mental status, nausea, vomiting, sudden onset of focal neurologic deficits, and headache. The most common risk factor for this pathology is a history of hypertension that is often poorly controlled. The diagnosis is confirmed with the CT scan which demonstrates punctate intraparenchymal bleeding. Treatment involves treating the underlying cause and blood pressure management. Let's also discuss why the other choices are incorrect. Choice 1, a history of alcohol abuse could predispose this patient to Wernicke-Korsakov encephalopathy, which presents with the triad of confusion, ataxia, and nystagmus. Choice 2, a recent fall causing sudden head trauma could cause an epidural hematoma, which may be referred to as talk-and-die syndrome, or a subdural hematoma. CT scan would demonstrate a lens-shaped lesion for an epidural hematoma or a crescent-shaped lesion for a subdural hematoma. Choice 3, chronic steady bleeding into the brain describes a chronic subdural hematoma. This pathology presents in the elderly and alcoholics with an insidious loss of consciousness and a crescent-shaped hyperdense lesion on head CT. Choice 4, deposition of plaques in the central nervous system describes Alzheimer's dementia, which presents with an insidious loss of memory. Finally, a bullet summary. Intraparenchymal hemorrhage is most commonly associated with poorly managed hypertension. That's all for this review about parenchymal hemorrhage. We hope that was helpful. This is the MedBullet Step 2 and 3 podcast, a daily audio review session for MedBullets, the free learning and collaboration community for medical student education. As a reminder, you can follow along with these podcast episodes by reviewing the topics directly on MedBullets.com. You can listen to these episodes on the MedBullets website or phone app while reading through the topic. If the MedBullets podcast has been valuable to you, we'd be thrilled if you consider leaving us a five-star rating and writing us a review on Apple Podcasts. It will help us spread the word and increase our discoverability tremendously. Thanks for tuning in. We'll see you all tomorrow, right here on the MedBullet Step 2 and 3 podcast.