Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) refers to a spontaneous or traumatic bleed into the brain parenchyma and is the 2nd-most common cause of cerebrovascular accidents (CVAs), commonly known as stroke, after ischemic CVAs. Trauma, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, vasculopathy, vascular malformations, tumors, coagulopathy, and hemorrhagic conversion of ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke may all be causative factors. Clinical presentation may vary depending on the size and location of the hemorrhage and may range from headache, neurologic signs and symptoms, and altered level of consciousness to coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma. Treatment includes stabilization, stopping or reversing of anticoagulation, blood pressure control, monitoring in a neurologic ICU, and possible neurosurgical intervention. Intracerebral hemorrhage is associated with significant morbidity and mortality.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Definition and Epidemiology

Definition

Intracerebral hemorrhage (ICH) refers to a spontaneous or traumatic bleed into the brain parenchyma and is the 2nd-most common cause of cerebrovascular accidents (CVAs).

Deep ICH:

  • Accounts for ⅔ of the cases of ICH
  • Affects the deeper structures within the cranial vault:
    • Basal ganglia Basal Ganglia Basal ganglia are a group of subcortical nuclear agglomerations involved in movement, and are located deep to the cerebral hemispheres. Basal ganglia include the striatum (caudate nucleus and putamen), globus pallidus, substantia nigra, and subthalamic nucleus. Basal Ganglia
    • Internal capsule
    • Brain stem Brain Stem The brain stem is a stalk-like structure that connects the cerebrum with the spinal cord and consists of the midbrain, pons, and medulla oblongata. It also plays a critical role in the control of cardiovascular and respiratory function, consciousness, and the sleep-wake cycle. Brain Stem
    • Cerebellum Cerebellum The cerebellum, Latin for "little brain," is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum

Lobar ICH:

  • Accounts for ⅓ of the cases of ICH
  • Affects structures of the cerebral cortex Cerebral cortex The cerebral cortex is the largest and most developed part of the human brain and CNS. Occupying the upper part of the cranial cavity, the cerebral cortex has 4 lobes and is divided into 2 hemispheres that are joined centrally by the corpus callosum. Cerebral Cortex and the superficial subcortical structures
  • Involves 1 or more lobes of the brain

Epidemiology

  • Spontaneous (atraumatic) ICH accounts for approximately 10% of CVAs.
  • Incidence:
    • Approximately 12–20 per 100,000 individuals
    • Doubles every 10 years in individuals 35 years and older
    • In the US, the incidence varies by ethnicity (highest to lowest):
      • Chinese and Japanese Americans
      • African Americans
      • Mexican Americans
      • Non-Hispanic White Americans
  • Slightly more common in men than in women

Etiology

Risk factors

  • Hypertension:
    • Most important risk factor
    • More than doubles the risk for ICH
  • Vasculopathy
  • Advanced age
  • Prior CVA
  • Coagulopathy:
    • Anticoagulant therapy
    • Antiplatelet therapy (minor increase in risk)
    • Thrombolytics Thrombolytics Thrombolytics, also known as fibrinolytics, include recombinant tissue plasminogen activator (TPa) (i.e., alteplase, reteplase, and tenecteplase), urokinase, and streptokinase. The agents promote the breakdown of a blood clot by converting plasminogen to plasmin, which then degrades fibrin. Thrombolytics
    • Inherited bleeding disorders
    • Chronic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease
  • CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
  • History of falls
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • Low cholesterol levels (especially LDL)
  • Lifestyle factors:
    • Sedentary lifestyle
    • Heavy dependence on alcohol
    • Tobacco use
    • Use of stimulant drugs:
      • Cocaine
      • Amphetamines
      • Sympathomimetics

Leading causes

  • Hypertensive vasculopathy:
    • Most common cause
    • Association with deep ICH is greater than that with lobar ICH.
    • Affected vessels include branches of:
      • Basilar artery
      • Posterior vertebral arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
      • Middle cerebral artery
    • Affected vessels largely supply:
      • Pons
      • Midbrain
      • Thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus
      • Globus pallidus
      • Putamen
      • Caudate nucleus
      • Cerebellar nuclei
    • Accelerates degenerative changes in the cerebral arterial/arteriolar branch points
    • Increased risk in the setting of comorbid vasculitis and/or coagulopathy
  • Cerebral amyloid angiopathy:
    • 2nd-most common cause
    • Association with lobar ICH is greater than that with deep ICH.
    • More common in the elderly
    • Amyloid accumulation in the arterioles of the cortex is causative.
    • Affected individuals are prone to recurrent ICH.

Other causes

  • Vascular malformations:
    • Arteriovenous malformations
    • Cavernous malformations
  • Thrombosis of the cerebral vein:
    • Most common in individuals with thrombophilia
    • Thrombosis increases venous pressure and leads to venous capillary rupture.
  • Hemorrhagic transformation of ischemic CVAs:
    • Common in large ischemic infarcts with significant associated cerebral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Common in ischemic infarcts of embolic origin
  • Primary tumors:
    • Glioma
    • Glioblastoma
    • Primary CNS lymphoma
    • Pineal tumors
    • Pituitary tumors
    • Meningioma Meningioma Meningiomas are slow-growing tumors that arise from the meninges of the brain and spinal cord. The vast majority are benign. These tumors commonly occur in individuals with a history of high doses of skull radiation, head trauma, and neurofibromatosis 2. Meningioma
    • Acoustic neuroma Acoustic neuroma Acoustic neuroma, also referred to as vestibular schwannoma, is a benign tumor arising from Schwann cells of the vestibular component of the cranial nerve VIII. Acoustic neuroma forms within the internal auditory meatus and extends into the cerebellopontine angle. Acoustic Neuroma
  • Metastatic tumors:
    • Melanoma Melanoma Melanoma is a malignant tumor arising from melanocytes, the melanin-producing cells of the epidermis. These tumors are most common in fair-skinned individuals with a history of excessive sun exposure and sunburns. Melanoma
    • Lung carcinoma
    • Choriocarcinoma
    • Renal cell carcinoma Renal cell carcinoma Renal cell carcinoma (RCC) is a tumor that arises from the lining of the renal tubular system within the renal cortex. Renal cell carcinoma is responsible for 80%-85% of all primary renal neoplasms. Most RCCs arise sporadically, but smoking, hypertension, and obesity are linked to its development. Renal Cell Carcinoma
    • Thyroid carcinoma
  • Infection of CNS structures:
    • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
    • Encephalitis Encephalitis Encephalitis is inflammation of the brain parenchyma caused by an infection, usually viral. Encephalitis may present with mild symptoms such as headache, fever, fatigue, and muscle and joint pain or with severe symptoms such as seizures, altered consciousness, and paralysis. Encephalitis
    • Brain abscess Brain abscess Brain abscess is a life-threatening condition that involves the collection of pus in the brain parenchyma caused by infection from bacteria, fungi, parasites, or protozoa. The most common presentation is headache, fever with chills, seizures, and neurological deficits. Brain Abscess
  • Mycotic aneurysms:
    • Originate from the emboli from infective endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis
    • May seed and infect the arterial wall causing weakening and aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms formation
  • Cerebral vasculitis: from the primary CNS or systemic vasculitis
  • Cerebral hypoperfusion syndrome:
    • May occur in chronic carotid artery disease after revascularization
    • Previously hypoperfused tissue accommodates poorly to the increased cerebral perfusion pressure.
  • Reversible vertebral vasoconstriction syndrome (RVCS):
    • Rare
    • Transient arterial narrowing that leads to thunderclap headache presentation
    • Vasoconstriction may cause hemorrhagic and/or ischemic parenchymal insults.

Pathophysiology

In the absence of trauma, cerebral parenchymal bleed generally results from the rupture of small penetrating arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.

Vascular rupture

Vascular rupture often occurs at or near the bifurcation of the affected arterioles and is attributed to degenerative vascular changes associated with:

  • Common vascular risk factors:
    • Advancing age
    • Hypertension
    • Diabetes
    • Smoking
  • Hypertensive vasculopathy:
    • Cumulative effect of aging and vascular shear forces
    • Hyperplasia of the intimal layer
    • Hyaline deposition in the vessel wall
    • Focal vessel wall necrosis
  • Cerebrovascular amyloid deposition:
    • Deposition of amyloid proteins between the media and adventitia
    • Subsequent extension into and degradation of the smooth muscle layer
    • Affects small arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries, arterioles, and capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries
    • Manifestations include perivascular inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, microaneurysms, and fibrinoid necrosis.

Hematoma expansion

Causes a mass effect leading to:

  • Increased intracranial pressure Increased Intracranial Pressure Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP) ( ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP))
  • Neurologic deterioration
  • Possible herniation

Perilesional edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema

  • Multiple contributing factors:
    • Mass effect
    • Perilesional neuronal ischemia
    • Release or accumulation of:
      • Vasoactive mediators (i.e., inflammatory vasodilators)
      • Cytotoxic mediators (i.e., cytokines)
  • May persist for days to weeks after the initial bleeding insult
  • Decreased perfusion to the perilesional cerebral parenchyma causes a secondary ischemic insult.

Vasogenic and cytotoxic mediator accumulation

  • Promotes edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema adjacent to the hematoma
  • Disrupts the blood–brain barrier
  • Causes neuronal sodium pump failure leading to neuronal death

Cessation of bleeding

  • Occurs via the intrinsic homeostatic pathways
  • Vascular tamponade is imposed by the cranial vault.
  • Impaired/delayed by the presence of coagulopathy (iatrogenic or pathologic)
  • Impaired/delayed by the presence of severely elevated blood pressure

Clinical Presentation

The signs and symptoms of ICH depend on the anatomical location and size of the hemorrhage.

General symptoms and signs

  • Symptoms:
    • Higher likelihood of occurrence and in presenting severely in larger hemorrhages compared with smaller hemorrhages:
      • Headache
      • Nausea/vomiting
      • Altered level of consciousness
      • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain/stiffness
    • Onset is most common at routine levels of exertion.
    • Hypertensive bleed: emotional or physical stress/exertion
    • Smaller/slower bleed: insidious onset of symptoms over minutes
    • Larger bleed: rapid progression of symptoms
  • Signs:
    • Severe blood pressure elevation
    • Meningismus
    • Altered level of consciousness
    • Seizure
    • Focal neurologic deficit
    • Progressive neurologic deterioration

Specific neurological findings

The following findings suggest rapidly progressive neurological impairment due to elevated ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP):

  • Pupillary palsy
  • Extraocular movement palsy
  • Progressive drowsiness
  • Cushing triad:
    • Bradycardia
    • Respiratory depression
    • Hypertension

Cardiac manifestations

  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) abnormalities:
    • ST-T wave inversions
    • QT interval prolongation
    • Ventricular dysrhythmia
  • Echocardiographic findings:
    • Reduced left ventricular ejection fraction
    • Focal or global wall motion abnormalities
  • Elevated cardiac biomarkers (generally, mild elevation):
    • Cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes:
      • Creatine kinase-MB (CKMB)
      • Troponin-I
      • Troponin-T
      • Troponin-C

Diagnosis

Intracerebral hemorrhage should be suspected in any individual presenting with neurologic signs or symptoms suggestive of a CVA. Prompt diagnosis is critical, as ICH is associated with significant morbidity and mortality.

Imaging

Noncontrast head CT:

  • Should be performed emergently
  • To distinguish between ischemic CVAs and ICH
  • Findings suggesting rapidly progressive neurological impairment due to elevated ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP):
    • Cerebellar hemorrhage:
      • > 3 cm in diameter
      • With neurologic deterioration
      • Compression of the brainstem
      • Ventricular obstruction leading to hydrocephalus
    • Intraventricular hemorrhage:
      • Ventricular enlargement indicating hydrocephalus
      • Neurologic deterioration
    • Supratentorial (hemispheric) hemorrhage:
      • Neurological deterioration
      • Brain compression
      • Hydrocephalus

Follow-up imaging:

  • Repeat CT/MRI appropriate for:
    • Evaluation of neurologic deterioration
    • Confirmation of hematoma stabilization
  • Brain MRI with contrast is the modality of choice to evaluate the underlying cause of ICH.
  • CT with contrast may be an option if MRI is contraindicated.
  • CTA or MRA to evaluate for vascular abnormalities

Laboratory evaluation

  • CBC
  • Comprehensive metabolic panel:
    • Electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes
    • BUN/creatinine
    • Hepatic transaminases
    • Glucose
  • Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies:
    • PT and INR
    • PTT
  • Urinalysis
  • Urine toxicology screen

Cardiac evaluation

  • Baseline ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG)
  • Cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes to evaluate for myocardial ischemia
  • Echocardiogram

Electroencephalography

Electroencephalography is indicated to evaluate seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures and unexplained encephalopathy.

Management

Acute ICH is an emergent neurologic situation that may sometimes require surgical intervention. Failure of prompt treatment could result in hemorrhagic expansion, parenchymal brain injury, elevated ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP), brain herniation, and ultimately death.

Stabilization

  • Evaluate and stabilize the affected individual using advanced trauma life support (ATLS) or advanced cardiac life support (ACLS) protocols.
  • Airway management and respiratory support, if indicated
  • Stop/reverse all anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants/ antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents.
  • Line placement (peripheral IV, central venous catheter Central Venous Catheter Central venous catheters are IV lines placed into the large central veins for monitoring of central venous pressure (CVP), prolonged drug administration, or administration of parenteral nutrition. The most common sites of insertion are the internal jugular and subclavian veins. Central Venous Catheter: Technique, arterial line)
  • Emergent neurosurgical consultation:
    • Surgical clinical decision-making
    • Placement of an ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)-monitoring device
    • Emergent CSF drainage for:
      • Severely elevated ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)
      • Obstructive hydrocephalus

General management

  • Noncontrast head CT as soon as possible
  • Assessment:
    • Baseline and serial neurologic examination
    • Repeat noncontrast CT immediately if deterioration is detected.
  • Cessation of bleeding:
    • Stop/reverse anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants/ antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents.
    • Order baseline coagulation studies.
  • Prophylactic measures:
    • Elevate the head of the bed.
    • Sedate agitated individuals.
    • Treat fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever.
  • Maintain eunatremia.
  • Prophylactic osmotic therapy:
    • Administration of hypertonic saline and/or mannitol
    • Administer prophylactic osmotic therapy:
      • If severe neurologic impairment on presentation
      • If rapid neurologic deterioration is detected
      • If there is a delay in imaging
      • If neurosurgical evaluation is delayed
  • Hyperventilation:
    • Induced by manipulation of ventilator settings
    • Induces cerebral vasoconstriction → reduced cerebral blood volume
    • Hyperventilation is a temporizing measure reserved for:
      • Individuals with acute brain herniation (until better definitive therapy is available)
      • Individuals with neurologic deterioration awaiting either urgent surgery or central venous access for osmotherapy

Emergent neurosurgical interventions

  • Placement of an invasive ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP) monitor:
    • Intraventricular monitor (gold standard)
    • Intraparenchymal device
    • Subarachnoid bolts
  • CSF drainage in case of:
    • Severely elevated ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)
    • Obstructive hydrocephalus

Blood pressure control

  • Blood pressure elevation may be the cause of hemorrhage.
  • Conversely, increased ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP) may cause blood pressure elevation.
  • Elevated blood pressure may be necessary to maintain cerebral perfusion in the setting of cerebral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema.
  • Pain due to ICH may also contribute to blood pressure elevation.
  • Choice of medication:
    • Systolic blood pressure > 160 mm Hg: nicardipine
    • Systolic blood pressure < 160 mm Hg: labetalol

Surgical intervention

  • CSF drainage:
    • Generally performed for obstructive hydrocephalus
    • Obstructive hydrocephalus may be seen in:
      • Thalamic hemorrhage → compression of the 3rd ventricle
      • Cerebellar hemorrhage → compression of the 4th ventricle
      • Extension of ICH into the ventricular space(s)
  • Craniectomy with hematoma evacuation
  • Other potential interventions:
    • Craniotomy with endoscopic hemorrhage aspiration
    • CT-guided stereotactic aspiration

Seizure management

  • Individuals with ICH often experience seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures:
    • Early seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures in the course of management:
      • Usually self-limiting
      • Attributed to acute neurochemical changes associated with ICH
    • Status epilepticus during the course of management
    • Late seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures after ICH stabilization:
      • Usually recurrent and also known as “post-stroke epilepsy Epilepsy Epilepsy is a chronic brain disorder marked by recurrent and unprovoked seizures. These seizures can be classified as focal or generalized and idiopathic or secondary to another condition. Clinical presentation correlates to the classification of the epileptic disorder. Epilepsy
      • Attributed to scarring/gliosis after ICH
  • Seizure prophylaxis is not recommended.
  • Acute (early) ICH-related seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures: immediate IV administration of antiepileptics
  • Post-stroke (late) seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures: long-term antiepileptic therapy

Prognosis

  • Mortality:
    • 30-day mortality rate: 30%–50%
    • 10-year survival rate: < 20%
  • Morbidity:
    • Residual neurologic impairment and associated disability
    • Cognitive impairment
  • Risk factors for poor outcomes:
    • Advanced age
    • Severe baseline neurologic impairment
    • Early neurologic deterioration
    • Premature or early withdrawal of support
    • Use of anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants/ antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents
    • Hematoma characteristics:
      • Large volume
      • Cerebellar location
      • Infratentorial location
      • Intraventricular extension
      • Early rebleeding

Differential Diagnosis

  • Ischemic stroke: an ischemic infarct of the cerebral parenchyma caused by the occlusion of a cerebral artery by atherosclerotic lesions or cardioembolic emboli. Ischemic stroke presents with neurologic deficits and/or altered mental status/altered level of consciousness that depends on the size and location of the infarct. Diagnosis is clinical and confirmed by neuroimaging. Management includes initial stabilization, possible cerebrovascular intervention, and addressing identifiable underlying etiologies (severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, embolus), and cardiovascular risk factors.
  • Other hemorrhagic cerebral conditions: Carotid/cerebral artery dissection, epidural hemorrhage Epidural Hemorrhage Epidural hemorrhage (EDH) is an event characterized by bleeding into the epidural space between the dural layers of the meninges and the skull. The primary mechanism triggering bleeding is trauma (i.e., closed head injury), which causes arterial injury, most commonly middle meningeal artery injury. Epidural Hemorrhage, intraparenchymal hemorrhage, and subdural hemorrhage Subdural Hemorrhage Subdural hemorrhage (SDH) is bleeding into the space between the dural and arachnoid meningeal layers surrounding the brain. The most common mechanism triggering the bleeding event is trauma (e.g., closed head injury) causing a tearing injury to the extracerebral "bridging" veins. Subdural Hemorrhage are other hemorrhagic manifestations of the cerebral vasculature that can present with neurologic deficits and/or altered mental status/altered level of consciousness. Diagnosis is clinical and confirmed by neuroimaging. Management depends on the hemorrhagic etiology and includes initial stabilization, neurosurgical/endovascular consultation, management of ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP), and monitoring in a neurologic ICU.
  • Hypertensive encephalopathy: neurologic deficits and/or altered mental status/altered level of consciousness that present in the setting of severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension. Diagnosis is based on the presence of elevated blood pressure and neurologic signs and symptoms. Neuroimaging is useful to rule out ischemic or hemorrhagic CVAs.

References

  1. Caplan, L. (2021). Clinical diagnosis of stroke subtypes. Retrieved September 21, 2021, from https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes
  2. Caplan, L. (2021). Overview of the evaluation of stroke. Retrieved September 21, 2021, from https://www.uptodate.com/contents/overview-of-the-evaluation-of-stroke
  3. Rordorf, G. (2021). Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis. Retrieved September 21, 2021, from https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis
  4. Rordorf, G. (2021). Spontaneous intracerebral hemorrhage: Acute treatment and prognosis. Retrieved September 21, 2021, from https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis
  5. Magdy, S. (2021). Spontaneous intracerebral hemorrhage: Secondary prevention and long-term prognosis. Retrieved September 21, 2021, from https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-secondary-prevention-and-long-term-prognosis
  6. Aguilar, M.I., Brott, T.G. (2011). Update in intracerebral hemorrhage. The Neurohospitalist, 1, pp. 148–159. Retrieved September 22, 2021, from https://doi.org/10.1177/1941875211409050

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