Intraparenchymal hemorrhage

Intraparenchymal hemorrhage (IPH) is one form of intracerebral hemorrhage in which there is bleeding within brain parenchyma. The other form is intraventricular hemorrhage (IVH). Intraparenchymal hemorrhage accounts for approx. 8-13% of all strokes and results from a wide spectrum of disorders.

see Intracerebral hemorrhage.

Intraparenchymal hemorrhage in the term infant is relatively uncommon.

Spontaneous intraparenchymal hemorrhage of term neonates is usually asymptomatic and does not require surgical intervention. However, there is no consensus on the management of cases with severe life-threatening symptoms, including repeated apnea, respiratory failure with severe cyanosis, severe bradycardia, or uncontrolled seizures.

Medical records of term neonates with intracranial hemorrhage who underwent surgical intervention were retrospectively reviewed. There were two cases with spontaneous parenchymal hemorrhage. Both cases were delivered vaginally without any use of forceps or vacuum devices. Neither of them showed asphyxia, hypoxic-ischemic encephalopathy, hematological abnormalities, congenital vascular anomalies, infection, or birth trauma. Common symptoms included apnea, cyanosis, bradycardia, and decreased consciousness. The original location of bleeding was the parenchyma of the right temporal lobe. The hemorrhage extended to subdural spaces in both cases. Subdural hematoma (SDH) removal was performed without manipulating the parenchymal hematoma. Only a small amount of SDH (approximately 5 ml) was drained spontaneously with irrigation, which was sufficient to decrease the elevated intracranial pressure. The patients' respiratory conditions improved dramatically after the surgery.

Tamura and Inagaki proposed that removing only a small amount of SDH would be effective and sufficient to relieve severe symptoms of increased intracranial pressure in term neonates with massive spontaneous parenchymal hemorrhage 1).

Bhanot et al. presented a patient with intraparenchymal hemorrhage due to cerebral arteriovenous malformation (AVM) who exhibited acute ST segment myocardial infarction (STEMI) after neurosurgery. Serial cardiac biomarkers and echocardiograms were performed which did not reveal any evidence of acute myocardial infarction. The patient was managed conservatively from cardiac stand point with no employment of anticoagulants, antiplatelet therapy, fibrinolytic agents, or angioplasty and recovered well with minimal neurological deficit. This case highlights that diffuse cardiac ischemic signs on the ECG can occur in the setting of an ICH after neurosurgery, potentially posing a difficult diagnostic and management conundrum 2).

Tamura G, Inagaki T. Removal of a minimal amount of subdural hematoma is effective and sufficient for term neonates with severe symptomatic spontaneous parenchymal hemorrhage. Childs Nerv Syst. 2019 Mar 16. doi: 10.1007/s00381-019-04114-2. [Epub ahead of print] PubMed PMID: 30879127.
Bhanot RD, Kaur J, Sriwastawa S, Bell K, Suchdev K. Postoperative 'STEMI' in Intracerebral Hemorrhage due to Arteriovenous Malformation: A Case Report and Review of Literature. Case Rep Crit Care. 2019 Apr 22;2019:9048239. doi: 10.1155/2019/9048239. PMID: 31231576; PMCID: PMC6507120.
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