CV

Intracerebral Hemorrhage

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Intracerebral Hemorrhage, Spontaneous Intracerebral Hemorrhage, Spontaneous Intracranial Hemorrhage, ICH, Cerebral Parenchymal Hemorrhage

  • Background
  1. Refers to Spontaneous Intracerebral Hemorrhage
  2. Trauma also causes Intracerebral Hemorrhage
  • Epidemiology
  1. Responsible for up to 15% of strokes in United States
  • Pathophysiology
  1. Associated with small vessel Cerebrovascular Disease
  2. Most commonly affects the Basal Ganglia and Thalamus
  • Causes
  • Common
  1. Hypertension
    1. Most common cause in adults with Spontaneous Intracerebral Hemorrhage
  2. Cerebral amyloid angiopathy
    1. Most common cause of non-Traumatic lobar Intracerebral Hemorrhage in older patients
  3. Arteriovenous Malformations (AVM)
    1. Most common cause of Intracerebral Hemorrhage in children
  • Causes
  • Other
  1. Septic cerebral embolism
  2. Intracranial Mass
  3. Anticoagulants or Thrombolytics
  4. Venous sinus thrombosis
  5. Encephalitis (e.g. HSV Encephalitis)
  6. Stimulant Drugs of Abuse (e.g. Cocaine, Methamphetamine)
  • Risk Factors
  1. Strenuous activity
  2. Oral Anticoagulants (especially Warfarin)
  3. Hypertension
  4. Heavy Alcohol use
  5. Increasing age
    1. Risk doubles every 10 years after age 35 years
  • Signs
  1. Focal and gradually progressive presentation of neurologic deficits developing over minutes to hours
  • Precautions
  1. Cerebellar bleeding can rapidly deteriorate
  • Management
  1. Similar overall management as for Subarachnoid Hemorrhage
  2. Opioid Analgesics for Headache may help to control Blood Pressure
  3. Differences with SAH management
    1. Aneurysm specific management does not apply to Intracerebral Hemorrhage
    2. Blood Pressure target in ICH appears to be <180 mmHg (instead of <140 target used for SAH)
      1. Control Blood Pressure while still maintaining Cerebral Perfusion Pressure
      2. Labetalol and Nicardipine are most often used to control Blood Pressure
      3. Qureshi (2016) N Engl J Med 375(11):1033-43 [PubMed]
  • Prognosis
  1. Higher mortality with decreasing alertness on presentation
  • References
  1. Burgess and Stowens (2014) Crit Dec Emerg Med 28(5): 2-13
  2. Rordorf and McDonald in Kasner (2014) Spontaneous Intracerebral Hemorrhage, Uptodate, accessed 5/8/2014