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Intracerebral Hemorrhage
Aka: Intracerebral Hemorrhage, Spontaneous Intracerebral Hemorrhage, Spontaneous Intracranial Hemorrhage, ICH, Cerebral Parenchymal Hemorrhage, Cerebral Intraparenchymal Hemorrhage
- See Also
- Cerebrovascular Accident
- Subarachnoid Hemorrhage
- Background
- Refers to Spontaneous Intracerebral Hemorrhage
- Trauma also causes Intracerebral Hemorrhage
- Epidemiology
- Responsible for up to 15% of strokes in United States
- Pathophysiology
- Associated with small vessel Cerebrovascular Disease
- Most commonly affects the Basal Ganglia and Thalamus
- Causes: Common
- Hypertension
- Most common cause in adults with Spontaneous Intracerebral Hemorrhage
- Cerebral amyloid angiopathy
- Most common cause of non-Traumatic lobar Intracerebral Hemorrhage in older patients
- Cerebral Arteriovenous Malformation (AVM)
- Most common cause of Intracerebral Hemorrhage in children
- Causes: Other
- Septic cerebral embolism
- Intracranial Mass
- Anticoagulants or Thrombolytics
- Venous sinus thrombosis
- Encephalitis (e.g. HSV Encephalitis)
- Stimulant Drugs of Abuse (e.g. Cocaine, Methamphetamine)
- Risk Factors:
- Strenuous activity
- Oral Anticoagulants (especially Warfarin)
- Hypertension
- Heavy Alcohol use
- Increasing age
- Risk doubles every 10 years after age 35 years
- Symptoms
- Severe Headache
- Vomiting
- Decreased Level of Consciousness
- Signs
- Focal and gradually progressive presentation of neurologic deficits developing over minutes to hours
- Precautions
- Cerebellar bleeding can rapidly deteriorate
- Management: General
- Similar overall management as for Subarachnoid Hemorrhage
- Opioid Analgesics for Headache may help to control Blood Pressure
- Differences with SAH management
- Aneurysm specific management does not apply to Intracerebral Hemorrhage
- 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 and Nicardipine are most often used to control Blood Pressure
- Qureshi (2016) N Engl J Med 375(11):1033-43 [PubMed]
- 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]
- Prognosis
- Higher mortality with decreasing alertness on presentation
- References
- Dreis (2020) Crit Dec Emerg Med 34(7):3-21
- Burgess and Stowens (2014) Crit Dec Emerg Med 28(5): 2-13
- Rordorf and McDonald in Kasner (2014) Spontaneous Intracerebral Hemorrhage, Uptodate, accessed 5/8/2014