Cerebral Intraparenchymal Hemorrhage

Aka: Cerebral Intraparenchymal Hemorrhage, Spontaneous Intraparenchymal Cerebral Hemorrhage, Spontaneous Intracerebral Hemorrhage, Intracerebral Hemorrhage, ICH, Cerebral Parenchymal Hemorrhage, Nontraumatic Intraparenchymal Cerebral Hemorrhage

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II. Background

  1. This page refers to Spontaneous Intracerebral Hemorrhage
  2. Contrast with Subarachnoid Hemorrhage (due to Cerebral Aneurysm, Cerebral AVM or Trauma)
  3. Trauma also causes Intracerebral Hemorrhage (in addition to Epidural Hematoma, Subdural Hematoma, SAH)

III. Epidemiology

  1. Spontaneous Intracerebral Hemorrhage is responsible for up to 9% of CVAs in U.S. (40,000 to 67,000 per year)

IV. Pathophysiology

  1. Intraparenchymal Hemorrhage is associated with small vessel Cerebrovascular Disease (penetrating arteries, arterioles)
  2. Most commonly affects the Basal Ganglia and Thalamus (but may affect Cerebrum, Cerebellum or Brain Stem)
  3. Neuronal injury mechanisms
    1. Poor perfusion from ruptured vessel
    2. Swelling from bleeding and inflammatory response further decreases perfusion

V. Causes: Primary Intraparenchymal Hemorrhage

  1. Background
    1. Primary Intraparenchymal Hemorrhage Accounts for 90% of cases
    2. Results from damaged small blood vessels due to Hypertension or Cerebral amyloid angiopathy (CAA)
    3. Damaged vessels are more prone to rupture which results in Intraparenchymal Hemorrhage
  2. Hypertension
    1. Most common cause in adults with Spontaneous Intracerebral Hemorrhage
    2. Hypertension results in degenerative changes in small perforating arteries, weakening their walls
    3. Typically affects Basal Ganglia, Thalamus, Brainstem, Cerebellum
  3. Cerebral amyloid angiopathy (CAA)
    1. Most common cause of non-Traumatic lobar Intracerebral Hemorrhage in older patients
    2. Beta amyloid accumulates in cortical blood vessels resulting in vascular weakening, microaneurysms
    3. Typically affects lobar regions
    4. Risk factors include advanced age, male, asian, Diabetes Mellitus, daily Alcohol. Anticoagulants, Sympathomimetics
    5. Matsukawa (2012) Acta Neurol Scand 126(2):116-21 +PMID: 22067041 [PubMed]

VI. Causes: Secondary Intraparenchymal Hemorrhage

  1. Cerebral Arteriovenous Malformation (AVM)
    1. Most common cause of Intracerebral Hemorrhage in children
  2. Hemorrhagic conversion of Ischemic Stroke
  3. Septic cerebral embolism
  4. Intracranial Mass
  5. Anticoagulants or Thrombolytics
  6. Coagulopathy
  7. Cerebral Venous Thrombosis
  8. Encephalitis (e.g. HSV Encephalitis)
  9. Stimulant Drugs of Abuse (e.g. Cocaine, Methamphetamine)
  10. Moyamoya Disease
  11. Mycotic aneurysm rupture
  12. Vasculitis

VII. Risk Factors:

  1. Tobacco Smoking
  2. Strenuous activity
  3. Oral Anticoagulants (especially Warfarin)
  4. Hypertension
  5. Heavy Alcohol use (>30 drinks/month or binge drinking)
  6. Increasing age
    1. Risk doubles every 10 years after age 35 years

VIII. Symptoms

  1. Severe Headache
  2. Vomiting
  3. Decreased Level of Consciousness
    1. Glasgow Coma Scale (GCS) <=12 in 60% of presentations
    2. Deterioration occurs in transport or with emergency department in 50% of patients

IX. Signs

  1. Focal and gradually progressive presentation of neurologic deficits developing over minutes to hours
  2. Hemiplegia
  3. Aphasia
  4. Cushing Triad
    1. Reflex response to reincreased ICP with large volume intraparenchymal Hemorrhage
    2. Hypertension
    3. Bradycardia
    4. Slow, irregular respirations

X. Labs

  1. Fingerstick Blood Sugar
  2. Complete Blood Count with Platelet Count
  3. Prothrombin Time (PT) or INR
  4. Partial Thromboplastin Time
  5. Troponin
  6. Electrocardiogram

XI. Imaging

  1. CT Head
    1. Obtain at presentation
    2. Identifies Hemorrhage location, ventricular extension and degree of surrounding edema
    3. Identifies mass effect, including midline shift and Cerebral Herniation
    4. Repeat Head CT (consult neurosurgery for recommendations)
      1. Consider repeat at 6 hours after first CT Head
      2. Consider repeat at 24 hours (esp. if Anticoagulant use)
      3. Repeat Head CT for any significant change in neurologic status
  2. CTA Head and Neck (CT Angiography)
    1. Spot Sign (extravasation of contrast in an expanding Hematoma)
    2. Identifies vascular cause of Hemorrhage in up to 15% of cases
      1. May also identify active, continued Hemorrhage
    3. Indications
      1. Lobar Hemorrhage in age <70 years old
      2. Deep or Posterior Fossa Hemorrhage in age <45 years (or <70 if no Hypertension history)
      3. Isolated Intraventricular Hemorrhage
      4. Any vascular etiology Hemorrhage
        1. Cerebral Arteriovenous Malformation (AVM)
        2. Dural Arteriovenous Fistula
  3. Other imaging
    1. Consider CT Venogram
    2. Consider MRI in stable patients

XII. Grading

  1. See Intracerebral Hemorrhage Score

XIII. Precautions

  1. Cerebellar bleeding can rapidly deteriorate

XIV. Management: General

  1. Similar overall management as for Subarachnoid Hemorrhage (SAH)
    1. Exceptions include aneurysm specific management and Blood Pressure targets
  2. ABC Management
    1. Endotracheal Intubation is frequently needed due to decreased GCS, aspiration risk
  3. Correct coagulation deficits and reverse Anticoagulants
    1. See Emergent Reversal of Anticoagulation
  4. Blood Pressure Management
    1. Opioid Analgesics for Headache may help to control Blood Pressure
    2. Blood Pressure target
      1. BP Target range is per local neurosurgical Consultation recommendations
      2. As of 2022 (AHA/ASA), if SBP 150-220 mmHg, then target SBP 140 mmHg (range 130 to 150 mmHg)
        1. For large spontaneous ICH or pending emergent surgical intervention, targets vary, but keep <180 mmHg
        2. Avoid dropping systolic Blood Pressure <130 mmHg
      3. If presenting systolic Blood Pressure >220 mmHg
        1. Avoid decreasing Blood Pressure by >20%
      4. Target continuous smooth and sustained Blood Pressure control (avoid wide fluctuations, infusions are preferred)
      5. Control Blood Pressure while still maintaining Cerebral Perfusion Pressure
      6. Initiate Blood Pressure management within 2 hours of diagnosis
        1. Goal BP range at target within one hour of starting control (do not delay for ICU transfer)
    3. Labetalol, Clevidipine and Nicardipine are most often used to control Blood Pressure (Esmolol may also be used)
      1. Avoid venous vasodilators (e.g. Nitroglycerin, Nitroprusside)
    4. Qureshi (2016) N Engl J Med 375(11):1033-43 [PubMed]
  5. Manage Seizures
    1. See Status Epilepticus
    2. More common in first 72 hours with large lobar intraparenchymal Hemorrhage with ventricular extension
    3. When used, Seizure Prophylaxis is most common with Levetiracetam (or Valproic Acid)
      1. Use Benzodiazepines as first-line initial agents in active Seizures (see Status Epilepticus)
      2. Phenytoin and Fosphenytoin are generally avoided (narrow therapeutic range, Drug Interactions)
    4. Seizure Prophylaxis indications (not recommended unless Seizures occur)
      1. Witnessed Seizure
      2. Seizure activity on EEG with Altered Level of Consciousness
  6. Early Neurosurgery Consultation
    1. Ventricular drainage indications
      1. Hydrocephalus
    2. Surgical drainage indications
      1. Hydrocephalus
      2. Increasing intraparenchymal Hemorrhage
      3. Clinical worsening
    3. Craniectomy indications
      1. Coma
      2. Large intracerebral Hematoma with midline shift
      3. Refractory high Intracranial Pressure
    4. Secondary lesion indications for neurosurgical intervention
      1. Hemorrhagic Brain Tumor
      2. Arteriovenous Malformation or fistula
      3. Cavernous malformation
      4. Distal or Mycotic aneurysm
      5. Moyamoya
  7. Disposition
    1. Admit to Intensive Care unit or dedicated stroke unit

XV. Management: Traumatic intraparenchymal Hemorrhage

  1. Expect Traumatic intraparenchymal Hemorrhage to stabilize within first 48 hours
  2. Neurosurgical decompression indications
    1. Neurologic deterioration or GCS <8
    2. Contusion volume >50 ml
    3. Frontal or temporal Contusion >20 ml
    4. Midline shift >5 mm
    5. Loss of subarachnoid space (basal cistern effacement)
    6. Bullock (2006) Neurosurgery 58(3 Suppl): S25-46 [PubMed]

XVI. Prognosis

  1. See Intracerebral Hemorrhage Score
  2. Higher mortality with decreasing alertness on presentation
  3. One year survival: 40%

XVII. References

  1. Chiara and Flint (2024) Crit Dec Emerg Med 38(12): 25-31
  2. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  3. Burgess and Stowens (2014) Crit Dec Emerg Med 28(5): 2-13
  4. Kreutzer and Maldonado (2022) Crit Dec Emerg Med 36(7): 16-7
  5. Marcolini and Swaminathan in Swadron (2023) EM:Rap 23(3): 3-6
  6. Rordorf and McDonald in Kasner (2014) Spontaneous Intracerebral Hemorrhage, Uptodate, accessed 5/8/2014
  7. Greenberg (2022) Stroke 53(7):e282-361 +PMID: 35579034 [PubMed]
  8. Gross (2019) JAMA 321(13): 1295-303 [PubMed]

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