• Clinical science

Intracerebral hemorrhage

Summary

Intracerebral hemorrhage (ICH) refers to bleeding within the brain parenchyma. While the term "intracranial hemorrhage" is often used synonymously, it in fact describes a broader range of phenomena. The most important underlying cause of ICH is arterial hypertension. Symptoms are often nonspecific (e.g., headache) but, depending on the affected vessel and cerebral region, focal neurologic deficits (e.g., hemiparesis) may occur. Compared to ischemic stroke, patients with ICH typically present with more severe headache and symptoms usually worsen more rapidly. A noncontrast head CT is the most important diagnostic procedure, and shows a hyperdense lesion in acute ICH or a hypodense lesion in hyperacute ICH. Treatment involves management of the underlying and accompanying conditions (e.g., hypertension) and, in some cases, neurosurgery. Approximately half of patients with ICH die within 30 days.

Etiology

References:[1][2][3][4][5]

Pathophysiology

  • Nontraumatic mechanisms of hemorrhage
    • Chronic arterial hypertension (→ lipohyalinosis of vessel walls) and/or cerebral amyloid angiopathy (→ deposition of β-amyloid in vessel walls) focal damage with formation of microaneurysms with elevated risk of ruptures
    • Structural abnormalities (e.g., vascular malformations) → parts of the abnormal vascular segment can be exposed to excessive strain → rupture
    • Venous outflow obstruction and stimulant use (e.g., cocaine) → acute arterial hypertension
    • Coagulopathies: impaired hemostasis → vascular microtrauma
    • Inflammatory tissue necrosis → damage to vessels
  • Traumatic: blunt or penetrating injury → damage to vessels

References:[6][3]

Clinical features

  • Symptoms usually worsen rapidly over minutes to a few hours
  • Severe headache
  • Nausea
  • Confusion; and loss of consciousness
  • Focal deficits depend on the etiology, location, and size of the hemorrhage (see stroke).

References:[3]

Diagnostics

  • Noncontrast cCT (confirmatory test): solitary hyperdense lesion, surrounded by hypodense edema (most commonly within the basal ganglia or internal capsule; see: “CT and MRI findings in early ischemia and hemorrhage” for more details)
  • Further diagnostics once hemorrhage is confirmed
    • Laboratory studies: CBC , coagulation parameters, blood glucose levels
    • Angiography → detection of vascular malformations and vasculitis

References:[3][7]

Treatment

Patients with signs of brain herniation should be operated on immediately!

References:[8][7][9][10]

Complications

References:[6][11]

We list the most important complications. The selection is not exhaustive.

Prognosis

Poor: ∼ 50% of patients die within 30 days.

References:[10]

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  • 2. Caplan LR, Kasner SE, Dashe JF. Etiology, Classification, and Epidemiology of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke. Last updated March 14, 2017. Accessed March 28, 2017.
  • 3. Rordorf G, McDonald C, Kasner SE, Wilterdink JL. Spontaneous Intracerebral Hemorrhage: Pathogenesis, Clinical Features, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis. Last updated December 4, 2013. Accessed March 28, 2017.
  • 4. Berlit P. Diagnosis and treatment of cerebral vasculitis. Ther Adv Neurol Disord. 2010; 3(1): pp. 29–42. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002614/.
  • 5. Chen M. Stroke as a Complication of Medical Disease. Semin Neurol. 2009; 29(2): pp. 154–162. doi: 10.1055/s-0029-1213735.
  • 6. Agabegi SS, Agabegi ED. Step-Up To Medicine. Baltimore, MD, USA: Wolters Kluwer Health; 2015.
  • 7. Liebeskind DS. Intracranial Hemorrhage. In: Intracranial Hemorrhage. New York, NY: WebMD. http://emedicine.medscape.com/article/1163977-overview. Updated May 10, 2016. Accessed March 1, 2017.
  • 8. Brunicardi F, Andersen D, Billiar T, et al. Schwartz's Principles of Surgery. McGraw-Hill Education; 2014.
  • 9. Hemphill JC, Greenberg SM, Anderson CS et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015; 46(7). doi: 10.1161/STR.0000000000000069.
  • 10. Rordorf G, McDonald C, Kasner SE, Wilterdink JL. Spontaneous Intracerebral Hemorrhage: Treatment and Prognosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-treatment-and-prognosis. Last updated May 21, 2014. Accessed March 29, 2017.
  • 11. Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol. 2012; 11(1): pp. 101–118. doi: 10.1016/S1474-4422(11)70264-2.
  • Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Education; 2015.
  • Daroff RB, et al. Bradley's Neurology in Clinical Practice. Elsevier.
  • Delcourt et al. Intracerebral hemorrhage location and outcome among INTERACT2 participants. Neurology. 2017; 88(15): pp. 1408–1414. doi: 10.1212/WNL.0000000000003771.
  • Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral haemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry. 2005; 76(11): pp. 1534–8. doi: 10.1136/jnnp.2004.055145.
last updated 08/12/2019
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