Intraparenchymal bleeds 

Type	Distribution	Hx	Notes	Management
Hypertensive	Deep grey (putamen, thalamus), pons, cerebellum  BG- 50% Thal - 15% BS/pons - 10-15% Cb - 10%	Hypertension	Pathophys:  - vessel wall hypertrophy/ischemia/necrosis => vessel wall replaced with collagen  - scar can fill lumen  (lipohyalinosis) => ischemia -charcot buchard aneurysmal weakening of scar  wall => bleed	- ABCD - Control ICP (suspect high ICP if coma, edema/effacement, blood in vents, HTN/bradycard) - INR < 1.5, plt > 100,000 - Control BP: goal CPP > 60, so MAP goal should be 60+ICP. If unknown ICP: MAP goal 90-100 (bc ICP>30-40 is unsurvivable anyways). If no ICP issues: goal SBP 120-160
Amyloid	Lobar (esp parietal, occip), NOT deep grey. GRE shows microhemorrhages in lobar distribution.	Old (>75), not hypertensive. If young, look for other pathology	Amyloid deposits in small vessels - unknown why deep vessels spared.	Don’t anticoagulate - very high risk of rebleed
DAI	Grey-white junction, corpus callosum, dorsal brainstem	High speed trauma	Punctate bleeds	Supportive
Contusion	Surface of convexity, anterior frontal, base of temporal lobes, coup-contrecoup (i.e occipital-frontal)	Trauma	- Pathophys: Brain scrapes against bumpy bone (temporal, frontal) - Trauma bleeds: mixed density, boggy tissue, edema.
Venous thrombosis	Temporal (esp post temp), b/l BG/thalamus, parasagittal	UC/IBD, OCPs, peripartum, HRT, kids with viral GI	- UC/IBD: hypercoag, + dehydration 2/2 diarrhea - Kids: dehydration 2/2 viral sickness	- Anticoagulate, even though there is blood in the head: Heparin gtt bridge to coumadin  - Look for clot (MRV/CTV)
Tumor	Anywhere	Hx of cancer	- Mets (chorio, thyroid, RCC, breast, lung, melanoma)  - GBM	depends on tumor type
Aneurysm	99% of the time, you will see SAH	aneurysmal SAH story	In isolated IPH, aneurysm is very unlikely, so no indication for immediate angio to look for one.	Aneurysms should be fixed immediately - AVMs and cavernomas should wait
AVM/AVF/cavernoma	“weird” location - non arterial or venous distribution: i.e. along tent (dural AVF), superficial lobar	Age < 50, not hypertensive	Cavs cant be seen on angio; need MRI in 1-2 mos after blood clears	AVMs and Cavernomas should not be fixed immediately - should give brain time to metaphorically cool down.

When to operate: 

- Relatively stronger indications: Cerebellar, rapidly deteriorating clinical status 

STICH I: 

- Lancet 2005;  data collected 1995-2003

- No difference in outcomes between early surgery and conservative treatment 

- Inclusion: spontaneous ICH > 2cm within 72 hrs, GCS > 5 

- Exclusion: secondary ICH (i.e. 2/2 aneurysm, AVM, tumor, trauma), bleed involving cerebellum or brainstem, severely disabled at baseline, couldn't undergo surgery within 24h of randomisation. 

Commentary/thoughts (from me) 

- the only group that seems to have any benefit are those with hematomas really close to the surface (<1cm), and even then, its just barely significant -- (OR 0.47-1.01) 

- 25% of the group randomized to conservative treatment ended up getting surgery-- like all neurosurgery trials, a lot of crossover to contend with. 

- people with GCS 5-8 who got surgery did much worse; in the context of 25% crossover, this finding may be confounded by a subset of people who are crashing and burning clinically and get emergent surgery as a heroic measure. In other words, this may be more indicative of poor slope of clinical function rather than a condemnation of surgery. Everyone who came in with GCS<8 in the trial ended up with an unfavorable outcome....

- the definition of a 'favorable' outcome was a function of prognosis - for older patients who came in with GCS<8, mRS 3 or less is considered favorable, which is fair but sad.