intracerebral hemorrhage (ICH)

Introduction

hemorrhage directly into the cerebral parenchyma

see intraparenchymal hemorrhagic stroke for

• cerebellar hemorrhage
• pontine hemorrhage

Etiology

• hypertension (most common)
  • putamen, thalamus, basal ganglia
• amyloid angiopathy (common in elderly)
  • suspect in patient with hemorrhage outside distribution common for hypertensive hemorrhage (supratentorial lobar hemorrhages)
• arteriovenous malformations (AVM)
• bleeding diatheses
• pharmacologic anticoagulation
• antiplatelet agents
  • combination of NSAIDs & antidepressants (NNH=244)
  • low dose aspirin 75-300 mg QD does not increase risk
• CNS infections
• brain tumor with hemorrhage
• cocaine may be precipitating factor
• tobacco abuse, alcohol abuse
• decreased LDL cholesterol increases risk
• increased HDL cholesterol increases risk
• SSRI use

Epidemiology

• intraparenchymal hemorrhagic strokes account for 15% of all strokes

Pathology

• most commonly small penetrating vessels in the putamen, thalamus bleed into the brain parenchyma
  • basal ganglia, pons, cerebellum also affected
• hypertension is a risk factor for hematoma expansion
• blood pressure > 140/80 mm Hg after intracerebral hemorrhage is associated with poor prognosis

Clinical manifestations

• 1/3 of non-comatose patients deteriorate rapidly
  • 50% mortality
• hematomas > 50 mL are most likely to cause deterioration
• patients with amyloid-related hemorrhages
  • frequently normotensive
  • generally have prior cognitive deficits

Laboratory

urine toxicology for cocaine

Diagnostic procedures

• cerebral angiography with catheter intra-arterial digital subtraction
  • patients < 45 years of age
  • intraparenchymal hemorrhage related to cocaine (high incidence of vascular anomalies)
  • spontaneous intraventricular hemorrhage without parenchymal hemorrhage
• continuous EEG monitoring
  • probably indicated for patients with mental status changes disproportional to the extent of brain injury

Radiology

• non-contrast computed tomography (CT) of the brain
• repeat neuroimaging may be required if changes in neurological status occur due to
  • expansion of hematoma
  • cerebral edema
• computed tomography angiography (CTA)
• venography
  • exclude central venous thrombosis
    • lobar spontaneous intracranial hemorrhage (ICH) in patients < 70 years
    • deep/posterior fossa hemorrhage in patients < 45 years or < 70 years without hypertension
• magnetic resonance angiography
  • spontaneous ICH & negative CTA/venography

Complications

• much higher mortality than ischemic stroke
  • 15-40% 90 day mortality

Differential diagnosis

• ischemic stroke can not be distinguished from intracranial hemorrhage on the basis of clinical manifestations
  • head CT without contrast distinguishes

Management

• see general measures under stroke (CVA)
• neurosurgery consultation
  • craniotomy for arteriovenous malformation (AVM)
  • benefits of surgery uncertain for supratentorial ICH
  • also see intracranial hemorrhage
• treatment of systolic hypertension > 180 mm Hg
  • avoid IV nitroprusside & nitroglycerin
    • nitroprusside & nitroglycerin may raise intracranial pressure
  • nicardipine or labetolol to maintain systolic blood pressure between 140-160 mm Hg; target systolic BP is 140 mm Hg
  • assumption is that excessively high systolic blood pressure will increase hematoma size
  • lowering of systolic BP to 140 mm Hg may not be harmful; may be helpful (no lower limit cited); may be harmful
  • target systolic blood pressure of 110-139 mm Hg does not improve outcomes relative to standard treatment of 140-179 mm Hg
  • maintain systolic BP 130-150 mm Hg, target systolic BP 140 mm Hg
  • avoid goals of systolic BP < 140 mm Hg
• mannitol, hypertonic saline, barbiturate coma, hyperventilation to reduce intracranial pressure
• do not use glucocorticoids to lower intracranial hypertension
• correct elevated INR
  • vitamin K IV for warfarin-associated intracranial hemorrhage
    • add 4-factor prothrombin complex concentrate
  • for patients taking direct oral factor Xa inhibitor (rivaroxaban, apixaban) stop the anticoagulant & treat with 4-factor prothrombin complex concentrate or andexanet alfa
  • for dabigatran reverse anticoagulation with idarucizumab
  • 4-factor prothrombin complex concentrate may have fewer complications & correct the INR more rapidly than fresh frozen plasma
  • 4-factor prothrombin complex preferable to fresh frozen plasma
  • recombinant factor VIIa of no benefit
• routine platelet transfusion not indicated
• statin use is controversial (not addressed in)
• prophylaxis for venous thromboembolism in non-ambulatory patients
  • pneumatic compression from hospital day 1
  • low dose LMW heparin
• postpone do not resuscitate order until at least the 2nd day of hospitalization
• for patients with spontaneous ICH, inpatient stroke unit indicated
• followup
  • neurorehabilitation
  • long-term goal of BP <130/80 is reasonable for prevention of recurrent ICH
  • avoid anticoagulants for 4 weeks
    • with or without mechanical heart valve
    • may decrease recurrence of ICH
    • pharmacologic prophylaxis for venous thromboembolism safe after 24 hours if no evidence of expanding hematoma
  • safe to restart antiplatelet agent after 11 weeks

More general terms

• hemorrhagic stroke