Intracerebral Hemorrhage

1. Overview

Intracerebral hemorrhage (ICH) is a hemorrhage within the brain tissue. In the past it was commonly referred to as “hypertensive hemorrhage,” but hypertension is a debatable etiology in many cases. Intracerebral hemorrhage (ICH) can generate a wide range of neurological symptoms, depending on its location.

2. Risk Factors

◆ Age: the incidence increases significantly after age 55 years and doubles with each decade of age.

◆ Gender: more common in men

◆ Race: in the U.S., ICH affects blacks more than whites. May be related to higher prevalence of HTN in blacks. Incidence may also be higher in Asians

◆ Previous stroke (any type)

◆ Alcohol consumption

◆ Cigarette smoking

◆ Street drugs

◆ Liver dysfunction

3. Etiologies

◆ Hypertension

◆ Vascular anomalies: arteriovenous malformation (AVM), aneurysm rupture, venous angioma rupture

◆ Arteriopathies: amyloid angiopathy, fibrinoid necrosis, cerebral arteritis.

◆ Brain tumor

◆ Coagulation or clotting disorders

◆ CNS infection

◆ Venous or dural sinus thrombosis

◆ Drug related: alcohol, sympathomimetics (cocaine, amphetamine)

◆ Posttraumatic

◆ Pregnancy related

◆ Postoperative

4. Clinical Presentation

In general, the neurologic deficit with ICH is characterized by a smooth progressive onset over minutes to hours, unlike embolic/ischemic stroke (brain tissue damage due to restricted blood supply) where deficit is maximal at onset. With ICH, severe headache, vomiting, and alterations in level of consciousness may be more common 

People with intracerebral bleeding have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed. Other symptoms include those that indicate a rise in intracranial pressure caused by a large mass putting pressure on the brain.

5. Examination

◆ CT scan: Non-contrast head CT scan is the usual initial imaging procedure of choice. It is rapid, has few contraindications, and easily demonstrates blood within the brain tissue immediately after hemorrhage. 

◆ CT angiography (CTA): CT angiography is a test that uses X-rays to provide detailed pictures of the blood vessels that go to the brain. A CT angiogram can show narrowed or blocked areas of a blood vessel. The patient would get an injection of a dye that makes it easier for doctors to see blood flow in the brain. It is very sensitive and specific in detecting vascular lesions(e.g. AVM or aneurysm), which is often the causes for a intracerebral hemorrahge.

6. Treatment Options

The decision to operate must be individualized based on patient’s neurologic condition, size and location of hemorrhage, patient’s age, and the patient’s expressed preferences (e.g. by a “living will”) and the family’s wishes concerning “heroic” measures in the face of catastrophic illness.

Often used surgical strategies:

◆ A craniectomy may take place, where part of the skull is removed to allow a swelling brain room to expand without being squeezed.

◆  Aspiration by stereotactic surgery or endoscopic drainage may be used in deep hemorrhages.

◆External ventricular drainage(EVD) is appropriate for intraventricular hemorrhage patients with neurologic deterioration in the setting of ventricular enlargement. EVD is a flexible plastic catheter placed into the brain ventricle by a neurosurgeon to aspirate or divert the excessive fluid inside ventricle.