II. Background
- Refers to Spontaneous Intracerebral Hemorrhage
- Trauma also causes Intracerebral Hemorrhage
III. Epidemiology
- Responsible for up to 6 to 20% of strokes in United States
IV. Pathophysiology
- Associated with small vessel Cerebrovascular Disease
- Most commonly affects the Basal Ganglia and Thalamus
V. Causes: Primary Intraparenchymal Hemorrhage
- Background
- Primary Intraparenchymal Hemorrhage Accounts for 90% of cases
- Results from damaged small blood vessels due to Hypertension or Cerebral amyloid angiopathy (CAA)
- Damaged vessels are more prone to rupture which results in Intraparenchymal Hemorrhage
-
Hypertension
- Most common cause in adults with Spontaneous Intracerebral Hemorrhage
- Hypertension results in degenerative changes in small perforating arteries
- Typically affects Basal Ganglia, Thalamus, Brainstem, Cerebellum
- Cerebral amyloid angiopathy (CAA)
- Most common cause of non-Traumatic lobar Intracerebral Hemorrhage in older patients
- Beta amyloid accumulates in cortical blood vessels resulting in vascular weakening
- Typically affects lobar regions
VI. Causes: Secondary Intraparenchymal Hemorrhage
-
Cerebral Arteriovenous Malformation (AVM)
- Most common cause of Intracerebral Hemorrhage in children
- Hemorrhagic conversion of Ischemic Stroke
- Septic cerebral embolism
- Intracranial Mass
- Anticoagulants or Thrombolytics
- Coagulopathy
- Cerebral Venous Thrombosis
- Encephalitis (e.g. HSV Encephalitis)
- Stimulant Drugs of Abuse (e.g. Cocaine, Methamphetamine)
- Moyamoya Disease
- Mycotic aneurysm rupture
- Vasculitis
VII. Risk Factors:
- Tobacco Smoking
- Strenuous activity
- Oral Anticoagulants (especially Warfarin)
- Hypertension
- Heavy Alcohol use (>30 drinks/month or binge drinking)
- Increasing age
- Risk doubles every 10 years after age 35 years
VIII. Symptoms
- Severe Headache
- Vomiting
-
Decreased Level of Consciousness
- Glasgow Coma Scale (GCS) <=12 in 60% of presentations
- Deterioration occurs in transport or with emergency department in 50% of patients
IX. Signs
- Focal and gradually progressive presentation of neurologic deficits developing over minutes to hours
- Hemiplegia
- Aphasia
X. Labs
- Fingerstick Blood Sugar
- Complete Blood Count with Platelet Count
- Prothrombin Time (PT) or INR
- Partial Thromboplastin Time
- Troponin
- Electrocardiogram
XI. Imaging
XII. Grading
XIII. Precautions
- Cerebellar bleeding can rapidly deteriorate
XIV. Management: General
- Similar overall management as for Subarachnoid Hemorrhage (SAH)
- Exceptions include aneurysm specific management and Blood Pressure targets
-
ABC Management
- Endotracheal Intubation is frequently needed due to decreased GCS, aspiration risk
- Correct coagulation deficits
-
Blood Pressure Management
- Opioid Analgesics for Headache may help to control Blood Pressure
- Blood Pressure target in ICH appears to be <180 mmHg (instead of <140 target used for SAH)
- Control Blood Pressure while still maintaining Cerebral Perfusion Pressure
- Labetalol, Clevidipine and Nicardipine are most often used to control Blood Pressure
- Qureshi (2016) N Engl J Med 375(11):1033-43 [PubMed]
- Manage Seizures
- See Status Epilepticus
- Routine Seizure Prophylaxis is not recommended unless Seizure occurs
- Early Neurosurgery Consultation
- Ventricular drainage indications
- Surgical drainage indications
- Hydrocephalus
- Increasing intraparenchymal Hemorrhage
- Clinical worsening
- Craniectomy indications
- Coma
- Large intracerebral Hematoma with midline shift
- Refractory high Intracranial Pressure
- Secondary lesion indications for neurosurgical intervention
- Hemorrhagic Brain Tumor
- Arteriovenous Malformation or fistula
- Cavernous malformation
- Distal or Mycotic aneurysm
- Moyamoya
- Disposition
- Admit to Intensive Care unit or dedicated stroke unit
XV. Management: Traumatic intraparenchymal Hemorrhage
- Expect Traumatic intraparenchymal Hemorrhage to stabilize within first 48 hours
- Neurosurgical decompression indications
- Neurologic deterioration or GCS <8
- Contusion volume >50 ml
- Frontal or temporal Contusion >20 ml
- Midline shift >5 mm
- Loss of subarachnoid space (basal cistern effacement)
- Bullock (2006) Neurosurgery 58(3 Suppl): S25-46 [PubMed]
XVI. Prognosis
- Higher mortality with decreasing alertness on presentation
- One year survival: 40%
XVII. References
- Dreis (2020) Crit Dec Emerg Med 34(7):3-21
- Burgess and Stowens (2014) Crit Dec Emerg Med 28(5): 2-13
- Kreutzer and Maldonado (2022) Crit Dec Emerg Med 36(7): 16-7
- Rordorf and McDonald in Kasner (2014) Spontaneous Intracerebral Hemorrhage, Uptodate, accessed 5/8/2014
- Gross (2019) JAMA 321(13): 1295-303 [PubMed]