Intracerebral hemorrhage

Definition
• Defined as abrupt onset of severe headache,
altered level of consciousness, or focal
neurological deficit associated with:
– a focal collection of blood within the brain parenchyma
on neuroimaging or at autopsy

• This is not due to trauma or hemorrhagic

conversion of a cerebral infarction

National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III. Stroke
1990; 21: 637–676.
 Epidemiology
• The incidence of ICH is defined as the
percentage of a population experiencing a first
ICH in a given time period.

• Various criteria are utilized in studying the

incidence:
– Hemorrhages associated with vascular malformations.
– Anticoagulants, thrombolytic agents, or illicit drugs.
– Methodological differences in case ascertainment.
– Imaging rates.
– Variations in population structure.
– Range of ages reported.
 Epidemiology
• In the Western hemisphere ranges from 10 to 30
cases per 100 000 persons.
– In Eastern sphere, ICH has larger percentage of all
strokes.

• Risk is marginally greater in men than in women.

– Blacks and Hispanics have significantly higher rates of
ICH than whites.
– Cerebellar hemorrhage accounts for 10% of ICH.
– Brainstem hemorrhage for 5–10% of ICH

Kissela B, Schneider A, Kleindorfer D, et al. Stroke in a biracial population: the excess burden of stroke among
blacks. Stroke 2004; 35: 426–431
Rothwell PM, Coull AJ, Giles MF, et al. for the Oxford Vascular Study. Change in stroke incidence, mortality, case-
fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004; 363:
1925–1933
 Proportional Distribution of ICH in
Different Studies
Total Lobar Deep Brainstem Cerebellum
ICH % % % %
Greater 1038 359 (35) 512 (49) 65 (6) 102 (10)
Cincinnati
Izumo City, 350 53 (15) 242 (69) 30 (9) 25 (7)
Japan
Southern 341 176 (52) 121 (36) 15 (4) 29 (9)
Sweden
Jyvaskyla
region, 158 53 (34) 77 (49) 11 (7) 17 (11)
Finland
Dijon, 87 16 (18) 58 (67) 5 (6) 8 (9)
France
Perth, 60 19 (32) 31 (52) 4 (7) 6 (10)
Australia
Flaherty ML, Woo D, Haverbusch M, et al. Racial variations in location and risk of intracerebral hemorrhage. Stroke
2005; 36: 934–937
Nilsson OG, Lindgren A, Stahl N, Brandt L, Saveland H. Incidence of intracerebral and subarachnoid haemorrhage in
southern Sweden. J Neurol Neurosurg Psychiatry 2000; 69: 601–607
 Risk factors for intracerebral hemorrhage
• Age and race
• Hypertension
• Cerebral amyloid angiopathy
• Apolipoprotein E
• Aneurysms and vascular malformations
• Anticoagulant- and thrombolytic associated ICH
• Antiplatelet drugs
• Cerebral microbleeds
• Prior cerebral infarction
• Hypocholesterolemia
• Heavy alcohol use
• Tobacco use
• Diabetes
• Heritability
Clinical presentation of symptoms by subtype
of stroke

Thrombosis Lacunar Embolus ICH SAH

Maximal 40% 38% 79% 34% 80%
at onset
Stepwise 34% 32% 11% 3% 3%

Gradual 13% 20% 5% 63% 14%

Fluctuating 13% 10% 5% 0% 3%

Mohr JP, Caplan LR, Melski JW, et al. The Harvard Cooperative Stroke Registry: a prospective registry.
Neurology 1978; 28: 754–762
 Mortality of ICH based on volume and
location of hematoma

Overall 30-day < 30 ml 30–60 ml > 60 ml

mortality (n=188)
Lobar 39% 23% 60% 71%
(n=66)
Deep
(n=76)
48% 7% 64% 93%

Pontine
44% 43% 100% N/A
(n=9)
Cerebellum 64% 57% 75% N/A
(n=11)
N/A=not applicable

Broderick J, Brott T, Duldner J, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use
predictor of 30-day mortality. Stroke 1993; 24: 987–993.
Annual age-specific, race-stratified incidence
rates of ICH*
200
180 Whites
160 Blacks
140
Incidence rate / 100 000

120
100
80
60
40
20
0
20-34 35-54 55-74 75-84 85+
Age

*Greater Cincinnati/Northern Kentucky region, 1998–2003

 Guidelines for Treating Elevated Blood Pressure
in Spontaneous Intracerebral Hemorrhage*

SBP MAP Elevated ICP CPP

1- >200mmHg
>150mmHg
or if
2- >180mmHg
or if >130mmHg Yes >60–80 mmHg

3- >180mmHg
>130mmHg No
or if
1-Consider aggressive BP reduction with continuous IV infusion
2-Consider monitoring ICP and reducing BP using intermittent or continuous IV
medications to keep CPP >60–80mmHg
3-Consider a modest reduction of BP (e.g., MAP of 110mmHg or target BP of
160/90 mmHg) using intermittent or continuous IV medications to control BP.

*Adapted from recommendations of American Heart Association/American Stroke Association

 European Stroke Initiative Recommendations for
Treating Elevated BP in Spontaneous ICH*
BP lowering is not routinely recommended.
Treatment is recommended if BP is elevated above the following levels:

a.170/100mmHg (or a MAP of 125 mmHg) is the recommended target BP in

patients with a known history of hypertension who have a SBP >180mmHg
and/or DBP >105 mmHg, if treated.
b.150/90mmHg (or a MAP of 110 mmHg) is the recommended target BP in
patients without a known history of hypertension who have a SBP >160mmHg
and/or DBP >95 mmHg, if treated.
c. Avoid reducing the MAP by more than 20%.
d. For patients monitored for elevated ICP, the BP limits and targets should be
adapted to higher values to guarantee a CPP >70 mmHg

**Intravenous labetalol, intravenous sodium nitroprusside or nitroglycerin and

captopril (per os) are the recommended drugs for BP treatment.

*Recommendations for the management of intracranial haemorrhage – part I: spontaneous intracerebral haemorrhage.
The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee.
Cerebrovasc Dis 2006; 22(4): 294–316.
• Common sites of a cerebral hemorrhage are:
 Basal ganglia (50%)

 Thalamus (10-15%)

 Pons (5-12%)

 Cerebellum (1-5%)

 Lobar intracerebral haemorrhage (20-50%)

 Frontal, temporal, parietal or occipital cortex