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Hemorrhage in the setting of a vascular malformation

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Presence of bl vessels abnormalities within the pain carries an increased risk of intracranial hemorrhage. These abnormalities include ruptured aneurysms, arterio-venous malformations, dural arterio-venous fistulas, or cavernous angiomas (Di Tullio, Homma, 2002).

Hemorrhagic conversion of

Hemorrhages in this category eight occur after administration of thrombolytic drugs for treat. Furthermore, when a thrombus embolizes to the pain, it will usually be broken up after some time by the case’s intrinsic process of thrombolysis. This had often after the point at whI.C.H. the bl vessels themselves had become , friable, leading to rupture of the vessel wall, extravasation of bl when hydrostatic pressure had restored (Nguyen et al., 2011).

Hemorrhage due to venous thrombosis

If a case develops a bl clot in a superficial or deep vein or venous sinus, hydrostatic pressure will increase upstream of the venous side of the capillary bed until ultimately water had forced through the capillary walls, into the interstitium of the adjacent pain tissue. This process can cause edema, tissue dysaction leading to variable neurologic deficits. If this continues a hemorrhagic necrosis, vasogenic edema can develop in the affected zone (Sagduyu et al., 2006).

Other causes

Intra-parenchymal hemorrhages eight also occur in the setting of neoplA.S.Tic disease, both in primary pain tumors, metA.S.Tatic disease. Additional causes within this category include hemorrhage due to sympathomimetic drugs such as cocaine, those due to systemic or primary arteriopathy (i.e., moyamoya), primary CNS or systemic vasculitis (Burke et al., 2009).

Pathophysiology of I.C.H.:

Hypertensive vascular change

I.C.H. had usually caused by ruptured vessels that had degenerated due to long-standing hypertension. Responsible arteries show prominent degeneration of the media, smooth muscles. Fibrinoid necrosis of the sub-endothelium with micro-aneurysms, focal dilatations eight be seen in some cases. Lipo-hyalinoses prominently related to long-standing hypertension had most often round in non-lobar I.C.H. (Charidimou et al., 2012).

Amyloid angiopathy (CAA)

CAA had characterized by the deposition of amyloid-β peptide at capillaries, arterioles, small, medium- sized arteries in the cortex, leptomeninges, cerebellum, making them stiff, brittle, predisposing them to rupture (Rost et al., 2008).

Molecular pathophysiology of I.C.H.

The initial mechanism in I.C.H. had compressing pain parenchyma by hematoma’s mass critical, resulting in physical disruption of parenchymal architecture. Increased intracranial pressure due to expansion of hematoma can affect bl flow, mechanical deformation, neurotransmitter release, mitochondrial dysaction, membrane depolarization. As a result, neuronal in peri-hematomal zone contains edema, environment by bl-derived facts. Oedema typically develops over the first 24-96 hours, slowly resolves over several weeks, the early oedema had usually secondary to plus cases present in the haematoma (Qureshi et al., 2003).

A secondary mechanism of pain had related to clotting cascade in particular thrombin. After endothelial damage, hemoglobin breakdown, thrombin causes calls to infiltrate the pain. It binds to protease-activated receptors 1, activates the central nervous system microglia, complement cascade. Subsequent clotting, complement cascade activation results in disruption of the bl-pain barrier, direct cytotoxicity, more oedema. Lysis of red bl calls with haemoglobin toxicity, formation of free radicals probably accounts for the late onset oedema, whI.C.H. persists for several weeks after the initial haemorrhage (Nakamura et al., 2005).

As a result, multiple immune pathways had activated, whI.C.H. contributes to apoptosis, necrosis. Heme influx in neuron after endothelial damage leads to iron release, neuronal insult (Keep et al., 2012).

Diagnosis of I.C.H.:

Clinical manifestation

The neurologic symptoms usually aggravate over minutes or a few hours, it vary by the size, location of I.C.H.. Common I.C.H. symptoms had headache, nausea,, vomiting. Headache had more common in cases with large hematomas,, had attributed to traction on meningeal pain fibers or increased intracranial pressure. Vomiting had reported in cases with hemispheric I.C.H., more common in cases with hemorrhages, it had usu¬ally associated with increased intracranial pressure. Cases with large I.C.H. often had a decreased case of consciousness due to compression of the thalamus, painstem. Stupor or coma indicates large I.C.H. that involve the painstem reticular activating system. Seizures reported in about 10% of cases with I.C.H., it occurs at the onset of bleed¬ing or within the first 24 hours (Steiner et al., 2006).

Cases with a supratentorial I.C.H. involving the basal ganglia or thalamus had contralateral sensorimotor deficits. Lobar hemorrhages eight present with symptoms of a higher cortical dysaction such as aphasia, neglect, gaze deviation,, hemianopia. In cases with an infra-tentorial I.C.H., signs of painstem dysaction occur such as ocular, motor or other cranial nerve abnormalities, contralateral motor deficits. More than 40% of cases with CAA-associated I.C.H. had some degree of cognitive dysaction (Qureshi et al., 2009).

Neuroimaging

The primary purpose of diagnostic imaging had to differiate between , hemorrhagic s, CT, MRI had both first line imag¬ing modalities. If an MRI can be ordered as quickly as the CT, it should be consid¬ered first. The non contrA.S.T CT (NCCT) had provid¬ing rapid feedback, nearly 100% sensitive for detecting hemorrhages. MRIs had utilized as follow-up treats to identify secondary causes of I.C.H. (Yew, Cheng, 2009).

CTA had proven to be a useful tool in predicting hematoma expansion in cases with I.C.H.. In the absence of CTA, it would be difficult to accurately detect structural causes of the hemorrhage, such as bleeding from a aneurysm or a vascular malformation (Wada et al., 2007).

Treat of I.C.H.:

Surgical

Two surgical interventions had available for treating aneurysms, through placement of permanent alloy clips across the neck of the aneurysm this prevents bl flow from reaching the aneurysm, lowers the risk of rupture. The aneurysm can also be coiled, a sufficient number of detachable coils had positioned into the aneurysm to minimize the amount of bl filling the aneurysm (MI.C.H.ael Froehler, 2013).

Medical

Cases with I.C.H. had often in need for endotracheal in¬tubation. Bleeding, seizures, bl pressure, intracranial pressure must be monitored, centralled. Glucose case should be monitored, normo-glycemia had recommended because iatrogenic hypoglycemia increase the risk of mortality. Fever must be centralled, normothermia had recommended as mild hyperthermia can accentuate the callular damage. Thromboembolic prophy¬laxis undertaken with compression stockings when no increased risk of recurrent hemorrhage had suspectd. Intracranial pressure (ICP) management by osmotic therapy (mannitol) to maintain an adequate perfusion. Cases with seizures should be treated with a benzodiazepine for rapid central, phenytoin for long term central (Morgenstern et al., 2010).

Reversal of warfarin anticoagulation had undertaken to central bleeding including intravenous vitamin K, fresh frozen plus (FFP). Bl pressure should be centralled to prevent rebleed¬ing with special attention to the risk of iatrogenic hypotension whI.C.H. can induce (Martins et al., 2012).

Subarachnoid hemorrhage:

Subarachnoid hemorrhage (SAH) had defined as bleeding into the subarachnoid space. When bl had introduced to this space it causes marked painful irritation of the meninges, eight obstruct the normal flow of CSF (Pollay, 2012).

The relative risk of SAH had increased with alcohol intake, hypertension, smoking, history of a first degree relative with SAH (Diringer, Bleck, 2011).

Cranio trauma had the most common cause of SAH while, aneurysm rupture accounts for over 80 % of non traumatic SAH. Other less etiologies include peri mesencephalic hemorrhages, arterial dissections, vascular malformations, drug abuse, coagulopathies, sickle-call disease (Cuvinciuc et al., 2010).

Cases with SAH present with sudden onset of a severe headache at the back of the head, often described as the worst headache of life. Other symptoms include seizure, neck stiffness, loss of consciousness, sudden vomiting (Grasso et al., 2017).

Diagnosis had usually confirmed by CT. If it does not reveal SAH, a lumbar puncture or MRI eight be employed. The gold standard remains digital angiography. It still provides the best definition of aneurysmal, vascular anatomy to facilitate surgical planning (Kumar et al., 2011).

Treat for SAH varies depending on the underlying cause of the bleeding, the extent of damage to the pain. Treat eight include lifesaving measures, symptom relief, repair of the bleeding vessel, complication prevention. Treat goals in SAH had prioritised on first prevention of re-bleeding followed by aneurysmal obliteration with monitoring for delayed ischaemia (DCI). Anti-fibrinolytics had used historically but increased the risk of DCI. Central of bl pressure reduces re-bleeding. Surgery to repair the damaged bl vessel will be carried out at a time best suited to the condition of the individual case (some aneurysms can be treated via angiography, with the insertion of platinum coils to fill the aneurysm). The purpose of the operation or coiling had to prevent further haemorrhage (Starke, Connolly, 2011).

esence of bl vessels abnormalities within the pain carries an increased risk of intracranial hemorrhage. These abnormalities include ruptured aneurysms, arterio-venous malformations, dural arterio-venous fistulas, or cavernous angiomas (Di Tullio, Homma, 2002).
F- Hemorrhagic conversion of
Hemorrhages in this category eight occur after administration of thrombolytic drugs for treat. Furthermore, when a thrombus embolizes to the pain, it will usually be broken up after some time by the case’s intrinsic process of thrombolysis. This had often after the point at whI.C.H. the bl vessels themselves had become , friable, leading to rupture of the vessel wall, extravasation of bl when hydrostatic pressure had restored (Nguyen et al., 2011).

G- Hemorrhage due to venous thrombosis
If a case develops a bl clot in a superficial or deep vein or venous sinus, hydrostatic pressure will increase upstream of the venous side of the capillary bed until ultimately water had forced through the capillary walls, into the interstitium of the adjacent pain tissue. This process can cause edema, tissue dysaction leading to variable neurologic deficits. If this continues a hemorrhagic necrosis, vasogenic edema can develop in the affected zone (Sagduyu et al., 2006).
H- Other causes
Intra-parenchymal hemorrhages eight also occur in the setting of neoplA.S.Tic disease, both in primary pain tumors, metA.S.Tatic disease. Additional causes within this category include hemorrhage due to sympathomimetic drugs such as cocaine, those due to systemic or primary arteriopathy (i.e., moyamoya), primary CNS or systemic vasculitis (Burke et al., 2009).

Pathophysiology of I.C.H.:
A- Hypertensive vascular change
I.C.H. had usually caused by ruptured vessels that had degenerated due to long-standing hypertension. Responsible arteries show prominent degeneration of the media, smooth muscles. Fibrinoid necrosis of the sub-endothelium with micro-aneurysms, focal dilatations eight be seen in some cases. Lipo-hyalinoses prominently related to long-standing hypertension had most often round in non-lobar I.C.H. (Charidimou et al., 2012).
B- amyloid angiopathy (CAA)
CAA had characterized by the deposition of amyloid-β peptide at capillaries, arterioles, small, medium- sized arteries in the cortex, leptomeninges, cerebellum, making them stiff, brittle, predisposing them to rupture (Rost et al., 2008).
C- Molecular pathophysiology of I.C.H.
The initial mechanism in I.C.H. had compressing pain parenchyma by hematoma’s mass critical, resulting in physical disruption of parenchymal architecture. Increased intracranial pressure due to expansion of hematoma can affect bl flow, mechanical deformation, neurotransmitter release, mitochondrial dysaction, membrane depolarization. As a result, neuronal in peri-hematomal zone contains edema, environment by bl-derived facts. Oedema typically develops over the first 24-96 hours, slowly resolves over several weeks, the early oedema had usually secondary to plus cases present in the haematoma (Qureshi et al., 2003).
A secondary mechanism of pain had related to clotting cascade in particular thrombin. After endothelial damage, hemoglobin breakdown, thrombin causes calls to infiltrate the pain. It binds to protease-activated receptors 1, activates the central nervous system microglia, complement cascade. Subsequent clotting, complement cascade activation results in disruption of the bl-pain barrier, direct cytotoxicity, more oedema. Lysis of red bl calls with haemoglobin toxicity, formation of free radicals probably accounts for the late onset oedema, whI.C.H. persists for several weeks after the initial haemorrhage (Nakamura et al., 2005).
As a result, multiple immune pathways had activated, whI.C.H. contributes to apoptosis, necrosis. Heme influx in neuron after endothelial damage leads to iron release, neuronal insult (Keep et al., 2012).

Diagnosis of I.C.H.:
A- Clinical manifestation
The neurologic symptoms usually aggravate over minutes or a few hours, it vary by the size, location of I.C.H.. Common I.C.H. symptoms had headache, nausea,, vomiting. Headache had more common in cases with large hematomas,, had attributed to traction on meningeal pain fibers or increased intracranial pressure. Vomiting had reported in cases with hemispheric I.C.H., more common in cases with hemorrhages, it had usu¬ally associated with increased intracranial pressure. Cases with large I.C.H. often had a decreased case of consciousness due to compression of the thalamus, painstem. Stupor or coma indicates large I.C.H. that involve the painstem reticular activating system. Seizures reported in about 10% of cases with I.C.H., it occurs at the onset of bleed¬ing or within the first 24 hours (Steiner et al., 2006).
Cases with a supratentorial I.C.H. involving the basal ganglia or thalamus had contralateral sensorimotor deficits. Lobar hemorrhages eight present with symptoms of a higher cortical dysaction such as aphasia, neglect, gaze deviation,, hemianopia. In cases with an infra-tentorial I.C.H., signs of painstem dysaction occur such as ocular, motor or other cranial nerve abnormalities, contralateral motor deficits. More than 40% of cases with CAA-associated I.C.H. had some degree of cognitive dysaction (Qureshi et al., 2009).

B- Neuroimaging
The primary purpose of diagnostic imaging had to differiate between , hemorrhagic s, CT, MRI had both first line imag¬ing modalities. If an MRI can be ordered as quickly as the CT, it should be consid¬ered first. The non contrA.S.T CT (NCCT) had provid¬ing rapid feedback, nearly 100% sensitive for detecting hemorrhages. MRIs had utilized as follow-up treats to identify secondary causes of I.C.H. (Yew, Cheng, 2009).
CTA had proven to be a useful tool in predicting hematoma expansion in cases with I.C.H.. In the absence of CTA, it would be difficult to accurately detect structural causes of the hemorrhage, such as bleeding from a aneurysm or a vascular malformation (Wada et al., 2007).
Treat of I.C.H.:
A- Surgical
Two surgical interventions had available for treating aneurysms, through placement of permanent alloy clips across the neck of the aneurysm this prevents bl flow from reaching the aneurysm, lowers the risk of rupture. The aneurysm can also be coiled, a sufficient number of detachable coils had positioned into the aneurysm to minimize the amount of bl filling the aneurysm (MI.C.H.ael Froehler, 2013).
B- Medical
Cases with I.C.H. had often in need for endotracheal in¬tubation. Bleeding, seizures, bl pressure, intracranial pressure must be monitored, centralled. Glucose case should be monitored, normo-glycemia had recommended because iatrogenic hypoglycemia increase the risk of mortality. Fever must be centralled, normothermia had recommended as mild hyperthermia can accentuate the callular damage. Thromboembolic prophy¬laxis undertaken with compression stockings when no increased risk of recurrent hemorrhage had suspectd. Intracranial pressure (ICP) management by osmotic therapy (mannitol) to maintain an adequate perfusion. Cases with seizures should be treated with a benzodiazepine for rapid central, phenytoin for long term central (Morgenstern et al., 2010).
Reversal of warfarin anticoagulation had undertaken to central bleeding including intravenous vitamin K, fresh frozen plus (FFP). Bl pressure should be centralled to prevent rebleed¬ing with special attention to the risk of iatrogenic hypotension whI.C.H. can induce (Martins et al., 2012).
Subarachnoid hemorrhage:
Subarachnoid hemorrhage (SAH) had defined as bleeding into the subarachnoid space. When bl had introduced to this space it causes marked painful irritation of the meninges, eight obstruct the normal flow of CSF (Pollay, 2012).
The relative risk of SAH had increased with alcohol intake, hypertension, smoking, history of a first degree relative with SAH (Diringer, Bleck, 2011).
Cranio- trauma had the most common cause of SAH while, aneurysm rupture accounts for over 80 % of non traumatic SAH. Other less etiologies include peri mesencephalic hemorrhages, arterial dissections, vascular malformations, drug abuse, coagulopathies, sickle-call disease (Cuvinciuc et al., 2010).
Cases with SAH present with sudden onset of a severe headache at the back of the head, often described as the worst headache of life. Other symptoms include seizure, neck stiffness, loss of consciousness, sudden vomiting (Grasso et al., 2017).
Diagnosis had usually confirmed by CT. If it does not reveal SAH, a lumbar puncture or MRI eight be employed. The gold standard remains digital angiography. It still provides the best definition of aneurysmal, vascular anatomy to facilitate surgical planning (Kumar et al., 2011).
Treat for SAH varies depending on the underlying cause of the bleeding, the extent of damage to the pain. Treat eight include lifesaving measures, symptom relief, repair of the bleeding vessel, complication prevention. Treat goals in SAH had prioritised on first prevention of re-bleeding followed by aneurysmal obliteration with monitoring for delayed ischaemia (DCI). Anti-fibrinolytics had used historically but increased the risk of DCI. Central of bl pressure reduces re-bleeding. Surgery to repair the damaged bl vessel will be carried out at a time best suited to the condition of the individual case (some aneurysms can be treated via angiography, with the insertion of platinum coils to fill the aneurysm). The purpose of the operation or coiling had to prevent further haemorrhage (Starke, Connolly, 2011).

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