Makindo Medical Notes

Related Subjects: |Subarachnoid Haemorrhage |Perimesencephalic Subarachnoid haemorrhage |Haemorrhagic stroke |Cerebellar Haemorrhage |Putaminal Haemorrhage |Thalamic Haemorrhage |ICH Classification and Severity Scores

🧠 Putaminal Haemorrhage is a common form of deep primary intracerebral haemorrhage, usually related to long-standing hypertension. It occurs within the putamen (part of the basal ganglia), which is central to motor control. Accounts for ~30–40% of all ICH cases and carries significant morbidity and mortality.

📊 Epidemiology

• Incidence: 30–40% of intracerebral haemorrhages.
• Age: Predominantly >60 years.
• Sex: More common in males.
• Geography: Higher prevalence in Asian populations.

🧬 Pathophysiology

• Rupture of deep penetrating arteries (lenticulostriates) due to chronic hypertension.
• Expanding clot raises ICP and compresses adjacent structures.
• Damage to the internal capsule → profound motor and sensory deficits.

⚠️ Causes

• Chronic hypertension (most common)
• Cerebral amyloid angiopathy (elderly)
• Anticoagulation / coagulopathy
• Brain tumours or metastases
• Substance misuse (esp. cocaine, amphetamines)
• Vascular malformations (rare)

🧾 Clinical Correlation with Location

• Anterior putamen:
  • Left: aphasia, abulia, contralateral weakness.
  • Right: behavioural changes, poor insight, aggression.
• Mid-putamen:
  • Compression of adjacent structures.
  • Left: global aphasia.
  • Right: neglect syndrome.
• Posterior putamen: contralateral hemianopia, sensory loss, limb ataxia.
• Medial bleeds: risk of rupture into ventricles → hydrocephalus, coma.

🩺 Clinical Presentation

• Sudden severe headache, nausea, vomiting.
• Focal neurological deficits (motor/sensory loss, speech disturbance).
• Altered consciousness → coma in severe cases.
• Raised ICP signs: papilloedema, bradycardia, hypertension, irregular breathing (Cushing’s triad).

⚠️ Complications

• Expansion of bleed → brainstem compression, herniation.
• Obstructive hydrocephalus.
• Seizures.
• Infection risk with CSF drains.
• Long-term disability (motor + cognitive).

🔬 Investigations

• CT head (non-contrast): first-line to identify bleed size, site, ventricular extension.
• MRI: for underlying lesions or delayed imaging.
• CTA / DSA: if vascular malformation suspected.
• Bloods: FBC, coagulation, U&E.
• ECG: monitor for arrhythmias due to raised ICP/stress.

💊 Management

• Stabilisation: ABCs, BP control (target SBP <140 mmHg).
• Reverse anticoagulation: e.g. Octaplex / Beriplex for warfarin.
• Medical therapy: antihypertensives, ICP control (mannitol, hypertonic saline), anticonvulsants if seizures.
• Surgery:
  • Ventriculostomy for hydrocephalus.
  • Clot evacuation in selected cases.
• Rehabilitation: MDT input – physio, OT, speech therapy, neuropsychology.

📈 Prognosis

• Mortality: high with large bleeds or intraventricular extension.
• Outcome depends on bleed size, GCS at presentation, and comorbidities.
• Survivors often left with significant neurological disability.

🛡️ Prevention

• Strict hypertension control (lifestyle + medication).
• Avoid unnecessary anticoagulation in high-risk patients.
• Substance misuse counselling.
• Regular follow-up for vascular risk factors.

🧪 Recent Advances

• Minimally invasive clot evacuation techniques (MIS, stereotactic aspiration).
• Neuroprotective agents in clinical trials.
• Advanced CT/MRI for prognostication and surgical planning.

📑 Clinical Guidelines

• Target systolic BP <140 mmHg (AHA/ESO guidelines).
• Immediate anticoagulant reversal if on warfarin/DOACs.
• Seizure prophylaxis considered if cortical involvement.

📚 References

• Hemphill JC et al. (2015). Guidelines for management of spontaneous ICH. Stroke.
• Broderick JP et al. (1993). Baseline NIHSS predicts outcome after ICH. Stroke.

🔗 Additional Resources

• American Stroke Association
• NCBI Bookshelf

🖼️ Images

• Figure 1: Anatomy of the putamen within the basal ganglia.
• Figure 2: Common haemorrhage sites within the putamen.