How to Work Up a Hemorrhagic Lesion in the Brain

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 Clinical questions  Processing notes  Useful hints

Introduction: Hemorrhage in the brain, just like any hemorrhage in other parts of the body, are either resulted from a disruption of the intact vasular structure and/or an abnormal coagulation status.

Clinical Questions: Head

• History of recent or remote trauma?

• History of hypertension?

• History of abnormal coagulation status? Is the patient on any anti-coagulation drug? Is there any abnormality in the blood and the hemopoietic system such as sickle cell anemia, leukemia, polycythemia vera, hyperviscosity state, etc.?

• History of familial cerebral angiopathy or stroke?

• Is there any thrombosis in the cavernous sinus, lateral sinus, and internal cerebral veins?

• History of drug abuse?

Processing note: Head

Gross Examination:

• Size, location, and extent must be documented accurately.

• Is the hemorrhage solitary or multiple?

• Is there any hemorrhagic infarction? Is there any hemorrhagic or non-hemorrhagic infartion distant from the source of hemorrhage (especially ruptured aneurysms)?

• Is there any mass effect and herniation?

• What is the size and shape of the hemorrhage? Is there any yellowish-brown discoloration suggestive of prior hemorrhage.

• What is the location of the hemorrhage?

• Document the atherosclerotic changes of the major vessels.  

Cleaning off the blood: If the hemorrhage is resulted from a ruptured aneurysm, the involved vessel should be dissected out and cleared of blood before fixation. Otherwise, it will be very difficult or even impossible to dissect the blood clot away from the aneurysm after fixation. If the aneurysm is fixed with the blood on it, the best way is to clean out the blood, dissect the blood vessel out and soak it in a normal saline with a little detergent overnight.

Intracerebral hemorrhage: When the source of bleeding lies inside the brain, it is often wise, before fixation, to extract as much of the clot as possible without disrupting the brain. This makes it easier to slice the brain after fixation. If the size of the clot is of interest, it can be weighed on its own.

Aneurysm with the rupture facing the surface of the brain may inject blood into the brain and simulate intracerebral hemorrhage with an intracerebral origin. This is particularly likely to happen when the aneurysm is embraced on the two sides by cerebral cortex.

Cavernous hemangioma may be macroscopically mistaken for fresh, sharply demarcated brain hemorrhages (remember Lucy's case). Such cavernous hemangiomas may be missed easily on histologic examination. The blood clot must be examined by a trichrome or reticulin stain which will demonstrate the cavernous malformation,

Useful Hints: Head

Spontaneous hemorrhage: Based on one study, the probablility that pathology is found in 9 out of 31 cases (only 17 cases has brain tissue, the other 14 cases have only blood in surgical specimen) of hemorrhage not associated with trauma or previously known histology have pathologic findings. Pathologi changes include amyloid angiopathy, arteriovenous malformation and tumor [Abrahams NA and Prayson RA, 2000]

Race: The relative frequency of non-traumatic intracranial hemorrhage is Caucasian: African American: Asian is about 1 : 2.5 : 6.

Epidural hematoma: usually due to the rupture of the meningeal artery. The middle meningeal artery is the most frequently involved one since the adjacent squamous part of the temproal bone is thin and susceptible to fracture.

Subdural hemorrhage in the brain does not extend into the spinal cord. Subarachnoid hemorrhage may extend into the spinal cord.

There is usually blood accumulation in avulsion of the spinal nerve root. However, the amount of blood can be very small.

By locations, spontaneous hemorrhage in the brain falls into four major types:

Subdural hemorrhage, subarachnoid hemorrhage, lobar hemorrhage, and deep structure hemorrhage.

Lobar hermorrhage is the hemorrhage that arises from the cortex and subcortical white matter.

Deep structure hemorrhage is the hemorrhage that occurs in deep structures such as the basal ganglia, thalamus, and infratentorial regions.(Note: hemorrhage that originates in the deep structures may dissect through the cortex and simulate a lobar hemorrhage.)

The commonest sites of "spontaneous" cerebral hemorrhage in the brain are lentiform nucleus (especially the putamen), thalamus, cerebellum, pons, subcortical regions, and the internal capsules.

Ventricular hemorrhage and subarachnoid hemorrhage: when the source of ventricular hemorrhage and subarachnoid hemorrhage is not found, and the amount is often small, the site of hemorrhage may be located in the spinal cord. A close examination of the spinal cord is therefore mandataory.

Size and shape: The size and shape of the hemorrhage can varies greatly. They can be in form of small punctate hemorrhage, slit hemorrhage, massive hemorrhage, ventricular casting and etc.

Apoplectic cyst: when a patient survive from an intracerebral hemorrhage, a remain of the hemorrhagic site and the surrounding tissue become a cyst with brown- or orange-stained wall in a few years.

Aneurysms: Aneurysms are most often formed at the point of bifurcation of cerebral arteries. When hemorrhage due to ruptured aneurysm is suspected, the aneurysm should be dissected and the point of hemorrhage identified before fixation. Aneurysms are often multiple, and the offending lesion is not necesarily the one most obvious in the angiogram.

Drug abuse that may cause intracranial hemorrhage and subdural hemorrhage and ischemic infarctions include:

Cocaine: due to hypertension induced by cocain. The distribution of hemorrhage is similar to that due to hypertension. Patient with a pre-existing AVM are much more vulnerable to cocaine induced rupture and hemorrhage. This is common in young patient. Cocaine abuse may also cause in utero ischemic infarction. Nasal septum defects may be a hint suggesting cocaine abuse.

Amphetamine is related to endothelial demage and vasculitis, necrosis of vessel in media and intima, patients are usually normotensive. Patients who are hypertensive and abuse amphatamine usually won't live long.

Sympathomimetics drug: ephedrine, pseudoephedrine, phenylpropanolamine.

Cerebral amyloid angiopathy (CAA):

• They are seen in normotensive adults over 60 years of age.

• Most of them are superficial, mainly affecting the cortex and subcortical white matter of the cerebral hemisphere. Cerebellum is rarely affected and the brain stem is least affected.

• Hematomas are usually not found in the areas where hemorrhage related to hypertension are found. They are usually small to mid sized and appear multilobated.

• Hematomas are usually admixed with findings indicative of prior hemorrhage and ischemia.

• Rarely, CAA may present as isolated subarachnoid hemorrhage.

Leukemia: Intraparenchymal hemorrhage associated with leukemia is usually due to rupture of the vessels. Hemorrhagic infarct due to reperfusion is a less common event.

Some causes of hemorrhage:

• Hemorrhage due to ruptured aneurysm.

• Hypertension (most common in the basal ganglia)

• Primary angiopathy of the CNS:

• Cerebral amyloid angiopathy

• CADASIL (Cerebral autosomal dominant angiopathy with subcortical infarcts and leukoencephalopathy

• MELAS (Mitochondrial encephalomyopathy, lactic acidosis and stroke like episodes)

• Hemorrhage due to anticoagulation therapy (usually multiple hemorrhage).

• Hemorrhage due to coagulopathy such as hemophilia, leukemia, and thrombocytopenia (usually multiple).

• Hemorrhage due to primary and secondary venous thrombosis (venous infarction).

• Hemorrhage in metastatic tumors: Hemorrhages are more frequently seen in metastatic melanoma, choriocarcinoma, lung cancers, and renal cell carcinoma.

• Hemorrhage in a hemangioma or arteriovenous malformation.

• Hemorrhage in a primary brain tumor.

• Hemorrhagic infarction.

• Vasculitis.

• Head injury.

• Use of cocaine will cause a transient increase of blood pressure and may cause hemorrhage.

• Miscellaneous causes (including Wernicke encephalopathy, diffuse axonal damage).

Relative frequency of Spontaneous intracranial hemorrhages in the young: