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may occur within brain parenchyma or the surrounding meningeal spaces. Hemorrhage
within the meninges or the associated potential spaces, including epidural hematoma,
subdural hematoma, and subarachnoid hemorrhage, is covered in detail in other articles.
Intracerebral hemorrhage (ICH) and extension of parenchymal bleeding into the ventricles
(ie, intraventricular hemorrhage [IVH]) are detailed here.
Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum
of disorders. Intracerebral hemorrhage is more likely to result in death or major disability
than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and
accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological
dysfunction. Substantial displacement of brain parenchyma may cause elevation of
intracranial pressure (ICP) and potentially fatal herniation syndromes.
Pathophysiology
Nontraumatic intracerebral hemorrhage most commonly results from hypertensive damage to
blood vessel walls (eg, hypertension, eclampsia, drug abuse), but it also may be due to
autoregulatory dysfunction with excessive cerebral blood flow (eg, reperfusion injury,
hemorrhagic transformation, cold exposure), rupture of an aneurysm or arteriovenous
malformation (AVM), arteriopathy (eg, cerebral amyloid angiopathy, moyamoya), altered
hemostasis (eg, thrombolysis, anticoagulation, bleeding diathesis), hemorrhagic necrosis (eg,
tumor, infection), or venous outflow obstruction (eg, cerebral venous thrombosis).
Nonpenetrating and penetrating cranial trauma are also common causes of intracerebral
hemorrhage.Patients who experience blunt head trauma and subsequently receive warfarin or
clopidogrel are considered at increased risk for traumatic intracranial hemorrhage. According
to one study, patients receiving clopidogrel have a significantly higher prevalence of
immediate traumatic intracranial hemorrhage compared with patients receiving warfarin.
Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving
warfarin.[1]
Predilection sites for intracerebral hemorrhage include the basal ganglia (40-50%), lobar
regions (20-50%), thalamus (10-15%), pons (5-12%), cerebellum (5-10%), and other
brainstem sites (1-5%).
Epidemiology
Frequency
United States
Each year, intracerebral hemorrhage affects approximately 12-15 per 100,000 individuals,
including 350 hypertensive hemorrhages per 100,000 elderly individuals. The overall
incidence of intracerebral hemorrhage has declined since the 1950s.
International
Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the
world.
Mortality/Morbidity
Annually, more than 20,000 individuals in the United States die of intracerebral hemorrhage.
Intracerebral hemorrhage has a 30-day mortality rate of 44%. Pontine or other brainstem
intracerebral hemorrhage has a mortality rate of 75% at 24 hours. Hallevi et al reviewed the
charts and CT scans of patients with intraventricular hemorrhage (IVH) to determine if the
extension of the hemorrhage could be measured. Clinical outcome was determined by the
modified Rankin Scale (mRS). IVH was also classified with an IVH score. The IVH score
allowed rapid estimate of IVH volume by the practitioner and increased predictability for
outcome.[2]
Race
Intracerebral hemorrhage has a higher incidence among populations with a higher frequency
of hypertension, including African Americans. A higher incidence of intracerebral
hemorrhage has been noted in Chinese, Japanese, and other Asian populations, possibly due
to environmental factors (eg, a diet rich in fish oils) and/or genetic factors.
Sex
Intracerebral hemorrhage has a slight male predominance, though study results have been
conflicting.
Age
In individuals younger than 45 years, lobar hemorrhage is the most common site of and
frequently is associated with AVMs.
Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in premature
infants.
History
Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with
progressive (ie, minutes to hours) development of the following:
A history of hypertension, trauma, illicit drug abuse, or a bleeding diathesis may be elicited.
Physical
Clinical manifestations of intracerebral hemorrhage are determined by the size and location
of hemorrhage, but may include the following:
Causes
Possible causes are as follows:
Hypertension[5]
Arteriovenous malformation
Aneurysmal rupture
Cerebral amyloid angiopathy
Intracranial neoplasm
Coagulopathy
Hemorrhagic transformation of an ischemic infarct
Cerebral venous thrombosis
Sympathomimetic drug abuse
Moyamoya
Sickle cell disease
Eclampsia or postpartum vasculopathy
Infection
Vasculitis
Neonatal intraventricular hemorrhage
Trauma
Differential Diagnoses
Acute Management of Stroke
Acute Subdural Hematoma
Anisocoria
Blood Dyscrasias and Stroke
Cardioembolic Stroke
Cerebellar Hemorrhage
Cerebral Amyloid Angiopathy
Cerebral Aneurysms
Cerebral Venous Thrombosis
Dissection Syndromes
Emergent Management of Subarachnoid Hemorrhage
Epidural Hematoma in Emergency Medicine
Head Injury
Herpes Simplex Encephalitis
Hydrocephalus
Lumbar Puncture (CSF Examination)
Magnetic Resonance Imaging in Acute Stroke
Moyamoya Disease
Neonatal Injuries in Child Abuse
Neurologic Effects of Cocaine
Neurological Sequelae of Infectious Endocarditis
Pediatric Status Epilepticus
Posttraumatic Epilepsy
Reperfusion Injury in Stroke
Secondary CNS Melanomas
Stroke Anticoagulation and Prophylaxis
Subdural Empyema
Thrombolytic Therapy in Stroke
Vascular Surgery for Arteriovenous Malformations
Vein of Galen Malformation
Laboratory Studies
See the list below:
Complete blood count (CBC) with platelets: Monitor for infection and assess
hematocrit and platelet count to identify hemorrhagic risk and complications.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): Identify a
coagulopathy.
Serum chemistries including electrolytes and osmolarity: Assess for metabolic
derangements, such as hyponatremia, and monitor osmolarity for guidance of osmotic
diuresis.
Toxicology screen and serum alcohol level if illicit drug use or excessive alcohol
intake is suspected: Identify exogenous toxins that can cause intracerebral
hemorrhage.
Screening for hematologic, infectious, and vasculitic etiologies in select patients:
Selective testing for more uncommon causes of intracerebral hemorrhage.
Imaging Studies
CT scan
CT scan readily demonstrates acute hemorrhage as hyperdense signal intensity (see image
below). Multifocal hemorrhages at the frontal, temporal, or occipital poles suggest a
traumatic etiology.
Perihematomal edema and displacement of tissue with herniation also can be appreciated.
Iodinated contrast may be injected to increase screening yield for underlying tumor or
vascular malformation.
MRI
The MRI appearance of hemorrhage on conventional T1 and T2 sequences evolves over time
because of chemical and physical changes within and around the hematoma (see Table 1
below).
Conventional T1 and T2 sequences are not highly sensitive to hemorrhage in the first few
hours, but newer gradient refocused echo sequences appear to be able to detect intracerebral
hemorrhage reliably within the first 1-2 hours of onset (see following images).
AVMs and cavernous angiomas may be identified by the presence of multiple flow voids
adjacent to the hematoma.
Paramagnetic contrast may be injected to increase screening yield for underlying tumor or
vascular malformation.
Permeability techniques, including use of source perfusion imaging data, may be used to
detect blood-brain derangements that precede hemorrhagic transformation after
thrombolysis.[8]
Vessel imaging
CT angiography permits screening of large and medium-sized vessels for AVMs, vasculitis,
and other arteriopathies.
MR angiography permits screening of large and medium-sized vessels for AVMs, vasculitis,
and other arteriopathies.
Consider catheter angiography for young patients, patients with lobar hemorrhage, patients
without a history of hypertension, and patients without a clear cause of hemorrhage who are
surgical candidates. Angiography may be deferred for older patients with suspected
hypertensive intracerebral hemorrhage and patients who do not have any structural
abnormalities on CT scan or MRI.
Other Tests
ECG frequently identifies cerebrum-induced dysrhythmia or cardiac injury.
Procedures
See the list below:
Lumbar puncture in the setting of IVH may reveal xanthochromia and a biochemical
profile similar to that observed in subarachnoid hemorrhage.
Ventriculostomy allows for external ventricular drainage in patients with
intraventricular extension of blood products. Intraventricular administration of
thrombolytics may assist clot removal.
Endoscopic hematoma evacuation may be a promising ultra-early stage treatment for
intracerebral hemorrhage that improves long-term prognosis. [9]
Histologic Findings
See the list below:
Staging
Table 2. Grading of Subependymal Hemorrhage (Open Table in a new window)
Medical Care
Medical therapy of intracranial hemorrhage is principally focused on adjunctive measures to
minimize injury and to stabilize individuals in the perioperative phase. Recent clinical trial
data suggests that treatment with recombinant factor VIIa (rFVIIa) within 4 hours after the
onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and
improves functional outcomes at 90 days.[10] However, further study of this medication in a
broader cohort did not result in improved clinical outcomes. This intervention may also result
in a small increase in the frequency of thromboembolic adverse events. The early use of
rFVIIa in patients with head injury without systemic coagulopathy may reduce the occurrence
of enlargement of contusions, the requirement of further operation, and adverse outcome.[11]
Perform endotracheal intubation for patients with decreased level of consciousness
and poor airway protection.
Cautiously lower blood pressure to a mean arterial pressure (MAP) less than 130 mm
Hg, but avoid excessive hypotension. Early treatment in patients presenting with
spontaneous intracerebral hemorrhage is important as it may decrease hematoma
enlargement and lead to better neurologic outcome.[12]
Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan.
Intubate and hyperventilate if intracranial pressure is increased; initiate administration
of mannitol for further control.
Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain
perfusion without exacerbating brain edema.
Avoid hyperthermia.
Correct any identifiable coagulopathy with fresh frozen plasma, vitamin K,
protamine, or platelet transfusions.
Initiate fosphenytoin or other anticonvulsant definitely for seizure activity or lobar
hemorrhage, and optionally in other patients.Levetiracetam has shown efficacy in
children for prophylaxis of early posthemorrhagic seizures.[13] Additional data suggest
that levetiracetam is more effective than phenytoin for seizure prophylaxis without
suppression of cognitive abilities in patients with ICH.[14]
Facilitate transfer to the operating room or ICU.
While reducing SBP with intravenous nicardipine hydrochloride does not
significantly reduce hematoma expansion in patients with ICH, the Antihypertensive
Treatment of Acute Cerebral Hemorrhage study supports further studies to evaluate
the efficacy of aggressive pharmacologic SBP reduction.[15]
Surgical Care
See the list below:
Neurosurgeon
Neurologist
Interventional neuroradiologist
Rehabilitation specialist
Diet
See the list below:
Activity
See the list below:
After hospital discharge, continued physical, occupational, and speech therapy may be
required.
Administer medications to control hypertension and to prevent complications such as
seizures, urinary tract infections, or venous thromboses.
Transfer
Following prehospital and emergent stabilization, patients with intracerebral hemorrhage
should be transferred to a medical facility with neurosurgical expertise.
Deterrence/Prevention
See the list below:
Complications
See the list below:
Prognosis
See the list below:
Patient Education
Educate patients regarding the following:
Treatment of hypertension
Warning signs and symptoms of stroke as well as preventive measures
Traumatic brain injury
Adverse effects of alcohol and sympathomimetic substances