💥A Comprehensive Review of Intraparenchymal Hemorrhage

🧠💥 Intraparenchymal Hemorrhage (IPH) – High-Yield Summary

Definition:
Spontaneous bleeding into brain parenchyma, causing direct tissue injury 🧩, mass effect, and secondary damage via edema 💧, inflammation 🧬, oxidative stress ⚡. Accounts for ~10–15% of strokes, highest mortality among stroke subtypes.

🔹 Pathophysiology 🧬

1. Primary Injury:
   • Rupture of small deep penetrating arteries 🩸 → hematoma formation
   • Direct tissue destruction 🧠 + mass effect → increased ICP 📊
2. Secondary Injury Cascade:
   • Perihematomal edema 💧
   • Inflammatory response 🧪
   • Cytotoxic enzyme release 🧬
   • Oxidative stress ⚡ → further neurological deterioration

🔹 Etiology & Risk Factors 🩺

1️⃣ Vascular Causes:

• Hypertension 🩸 – 50–60% (lipohyalinosis, fibrinoid necrosis)
• Cerebral Amyloid Angiopathy (CAA) 🧪 – especially elderly, lobar bleeds

2️⃣ Structural & Other Causes:

• Vascular malformations: AVMs, cavernomas 🌐
• Tumors 🧬
• Coagulopathies (inherited or iatrogenic ⚗️)
• Cerebral venous thrombosis
• Sympathomimetic drugs 💊

3️⃣ Modifiable Risk Factors:

• Chronic hypertension 🩸
• Excessive alcohol 🍷
• Anticoagulant therapy 💊

🔹 Clinical Presentation & Diagnosis ⚡

Symptoms:

• Sudden severe headache 🤕
• Nausea / vomiting 🤢
• Focal neurological deficits (location-dependent 🧠)
• Rapidly declining consciousness 🛌

Examples by Location:

• Putamen: contralateral hemiparesis ✋
• Thalamus: sensory loss, vertical gaze palsy 👀
• Cerebellum: ataxia, nystagmus, dizziness 🤸‍♂️
• Brainstem (pontine): coma, decerebrate posturing 🛌

Investigations 🖥️:

• Non-contrast CT: first-line, hyperdense blood
• MRI (GRE / SWI): detect underlying lesions
• CT Angiography (CTA): vascular anomalies, “spot sign” predicts expansion
• CSF / Labs: if infection or coagulopathy suspected

🔹 Management 🏥

1️⃣ Medical Management:

• ICU monitoring 🏥
• Aggressive BP control 🩸 (target <140 mmHg)
• Coagulopathy reversal ⚗️: vitamin K, PCC, FFP, DOAC reversal
• ICP management 🧠: head elevation, mannitol / hypertonic saline, sedation

2️⃣ Surgical Management ⚒️:

• Cerebellar hemorrhage >3 cm with deterioration → urgent evacuation
• Supratentorial hemorrhage: evidence limited; STICH trials show selective benefit
• Minimally invasive techniques 🧬: stereotactic aspiration + thrombolysis under study

🔹 Prognosis & Outcomes 📊

• 30-day mortality: ~40% (half in first 48 hours)
• Poor prognostic factors:
  • Advanced age 👵👴
  • Low GCS at presentation
  • Large hematoma volume 🧠
  • Intraventricular extension
  • Infratentorial location
  • Ongoing anticoagulation 💊
• Survivors: significant disability
  • Persistent motor, sensory, cognitive, speech deficits
  • Long-term rehab often required 🏋️‍♂️
  • Measured with modified Rankin Scale 📏

💡 Key Pearls

Surgery mainly for cerebellar or superficial lobar hemorrhages ⚒️

Hypertension = most common modifiable cause 🩸

CT scan 🖥️ = first-line rapid diagnosis

Hematoma volume & location predict prognosis 📊

Early detection & BP control ↓ hematoma expansion