Pathophysiology

The rupture of a vessel or microaneurysm causes the sudden development of a hematoma as the blood emerges at arterial pressure. Bleeding may be temporarily arrested but then continues, leading to a slowly evolving clinical deficit. The development of a mass effect ( Fig 1) due to the volume of the hematoma and associated edema causes both a generalized increase in intracranial pressure and the development of pressure gradients which cause shift across the midline or between compartments. If intracranial pressure rises rapidly, the patient may complain of severe headache and lapse into immediate coma. In others developing a mass effect less acutely the clinical features include declining alertness, the appearance of a third-nerve palsy, or the development of an extensor plantar response ipsilateral to a supratentorial hematoma or bilateral extensor plantar responses with a cerebellar bleed. The hematoma disrupts some tissue, but the neurological deficit is also due to the acute displacement of fiber tracts and may not be permanent. Blood may escape into the cerebrospinal fluid, causing blood staining and later xanthochromia of cerebrospinal fluid, but lumbar puncture is contraindicated because of the risk of herniation if pressure gradients are exaggerated by removal of fluid. The hemorrhage may also breach the ventricular wall with blood appearing in the ventricles ( Fig 2). The blood in a hematoma resolves over 10 days to 3 weeks. Hematomas are generally found in the basal ganglia, particularly in the putamen and thalamus, the lobar white matter, and the cerebellum or pons ( Oie.m§n.D...a.D.d.M.2hl.l9.Z5). Rarely, a hematoma in the region of the external capsule slowly splits white matter fibers, extending itself fore and aft, and undercutting the gray matter of the cortex. If a hematoma is lobar, the chances of finding an arteriovenous malformation, tumor, or amyloid, or the patient being on anticoagulants, are all higher. Angiography is often indicated in normotensive patients with lobar hematomas, although it may still miss a small angioma and amyloid angiopathy is not detectable.

Fig. 1 CT showing cerebral hemorrhage with mass effect.
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