Intracerebral Hematoma

An intracerebral hematoma (ICH) is a well-defined collection of blood within the brain parenchyma (functional tissue). Most ICHs are related to stroke or cerebral contusions; they account for approximately 10% of all strokes and are more likely than ischemic strokes to result in death or disability. Nontraumatic ICH commonly results from hypertensive damage to blood vessels but could also result from a ruptured aneurysm or other conditions. ICHs also complicate traumatic brain injury (TBI) in 2% to 3% of all head-injured patients. Although they are more frequently associated with closed-head injuries, they can also occur as a result of an open or penetrating injury or a depressed skull fracture. Similar to cerebral contusions, injury-related ICHs tend to occur most commonly in the frontal and temporal lobes and are uncommon in the cerebellum. They can also occur deep within the hemispheres in the paraventricular, medial, or paracentral areas in association with the shearing strain on small vessels that occurs with diffuse axonal injuries.

The patient can experience deterioration in cerebral functioning at the time of injury or in the first 48 to 72 hours after injury. Late hemorrhage into a contused area is possible for as long as 7 to 10 days after injury. ICHs result in a mortality rate between 25% and 72%. Complications include intracranial hypertension, brain herniation, and death.

Causes ⬆ ⬇

In cases in which there is no apparent cause for spontaneous ICH, hypertension is the most frequently associated disease. Other potential causes of ICH include hemorrhage at the site of a brain tumor and stroke. Stroke results from hypertensive damage to the blood vessel wall, rupture of an aneurysm, or bleeding from an arteriovenous malformation. Traumatic causes of ICH include depressed skull fractures, penetrating missile injuries (gunshot wounds or stab wounds), or a sudden acceleration-deceleration motion. Depressed skull fractures cause penetration of bone into cerebral tissue. A high-velocity penetration (bullet) can produce shock waves that are transmitted throughout the brain in addition to the injury caused by the bullet directly. A low-velocity penetrating injury (knife) may involve only focal damage and no loss of consciousness. Motor vehicle crashes (MVCs) cause rapid acceleration-deceleration injuries.

Genetic Considerations ⬆ ⬇

Spontaneous ICH has been seen in familial congenital coagulation disorders such as factor XI deficiency.

Sex and Life Span Considerations ⬆ ⬇

About 20,000 people die from ICH in the United States each year. The peak incidence occurs in childhood (ages 3 to 12 years) and in older adults (ages 50 to 70 years). ICH can occur as a result of TBI, the leading cause of all trauma-related deaths. Many of these deaths are associated with MVCs. Males ages 15 to 24 years are three times more likely than females to be injured in a crash. Falls are the most common cause of TBI in adults over age 65 years. ICH can also occur from nontraumatic causes such as stroke, the third leading cause of death in the United States. Although a stroke can occur at any age, 72% occur in people over 65 years of age.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Hypertension and trauma may lead to ICH. Black persons have higher rates of intracerebral hemorrhage and ICH as compared to White persons, likely due to the higher prevalence of hypertension in Black persons. Asian Americans also have higher rates of ICH, perhaps related to the fish oil content in their diet.

In recent years, Black persons have been killed in traffic crashes at a rate almost 25% higher than White persons (National Highway Traffic Safety Administration [NHTSA], 2021). Native American persons have the highest rate of MVC injury in the United States, more than twice the rate of Black persons (NHTSA, 2021). Experts have noted that Black and Native American communities tend to be crisscrossed by more dangerous roads than other locations, placing people from those communities at risk for injury. Black youth ages 15 to 24 years have the highest homicide rate from gunshot wounds in the United States, followed by Hispanic youth. Penetrating injuries from gunshot wounds and stab wounds are more common in non-Hispanic Black persons than in non-Hispanic White persons, making Black youth at risk for ICH related to penetrating injuries. Stark disparities exist with the incidence, management, and rehabilitation of TBI. The Centers for Disease Control and Prevention (CDC) report that Native American children and adults have the highest TBI-related hospitalizations and deaths in the United States. Important health disparities exist in treatment, follow-up, and rehabilitation of TBI. Non-Hispanic Black and Hispanic patients are less likely to receive follow-up care and rehabilitation following TBI and more likely to have poor psychosocial, functional, and employment-related outcomes as compared to non-Hispanic White patients (CDC, 2021).

The CDC report that in the 20 years since the year 2000, more than 400,000 U.S. service members were diagnosed with TBI, including active military service members and Veterans. Approximately 80% of these injuries occurred when the service members were not deployed. These injuries may result in ongoing symptoms, posttraumatic distress syndrome, and suicidal thoughts. People in correctional or detention facilities, people who experience homelessness, and survivors of intimate partner violence may have long-term consequences from TBI. People with lower incomes and those without health insurance have less access to TBI care, are less likely to receive surgical procedures and cranial monitoring when indicated, less likely to receive rehabilitation, and more likely to die in the hospital. Recent work has shown that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the risk of traffic injury in narrow rural roads, the lack of graded curves and lighted traffic signals on rural highways, and the distance from major trauma centers. Many of the most dangerous occupations, such as mining and agriculture, are found in rural areas and can result in injury, disability, and death. People living in rural areas who experience a TBI have more time to travel to get emergency care, less access to high-level trauma care, and more difficulty accessing TBI services. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury, and therefore are at risk for TBI and ICH (Healthy People 2020).

Global Health Considerations ⬆ ⬇

While there are few data available about global trends, people who live in Asia have a higher incidence of intracerebral hemorrhage than people living in other regions of the world, as do people with Asian ancestry living in the United States.

Assessment ⬆ ⬇

ASSESSMENT

History

If the patient has a suspected stroke, determine the onset of symptoms and whether the patient has a history of hypertension. Elicit a history of headache, drowsiness, confusion, seizures, focal neurological deficits, dizziness, irritability, giddiness, visual disturbances (seeing stars), and gait disturbances. Determine if the patient experienced nausea or vomiting. In addition, others may describe symptoms related to increased intracranial pressure (ICP), such as increased drowsiness or irritability and pupillary dilation on the ipsilateral (same as injury) side. Generally, patients suspected of ICH have a history of traumatic injury to the head or an alteration in level of consciousness from a stroke. In trauma patients, if the patient is not able to report a history, question the prehospital care provider, significant others, or witnesses about the situation and timing of the injury. If the patient was in an MVC, determine the speed and type of the vehicle, the patient's position in the vehicle, whether the patient was restrained, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a helmet. Determine if the patient experienced momentary loss of reflexes, momentary arrest of respirations, and possible retrograde or antegrade amnesia (loss of memory for events immediately before the injury or loss of memory for events after the injury). Ask about the patient's drinking history prior to the event.

Physical Examination

The most common symptoms are alterations in level of consciousness, headache, nausea, and vomiting. Seizures and focal neurological deficits may occur. When you examine the patient, note that, just as in cerebral contusions, small frontal lesions may be asymptomatic, whereas larger bilateral lesions may result in a frontal lobe syndrome of inappropriate behavior and cognitive deficits. Dominant hemispheric lesions are often associated with speech and motor deficits. Because many of the symptoms of alcohol intoxication mimic those of TBI, never assume that a decreased level of consciousness is caused by alcohol intoxication alone (even if you can smell the alcohol on the patient's breath or clothing) rather than a head injury (see Stroke for physical examination and treatment of stroke).

First evaluate and stabilize the patient's airway, breathing, and circulation with particular attention to the intactness of the patient's cervical spine (do not flex or extend the neck until you know the patient has no cervical spine injury). Next, perform a neurological assessment, watching for early signs of increased ICP: decreased level of consciousness, decreased strength and motion of extremities, reduced visual acuity, headache, and pupillary changes.

During the complete head-to-toe assessment, be sure to evaluate the patient's head for external signs of injury. Check carefully for scalp lacerations. Check the patient for cerebrospinal fluid (CSF) leakage from the nose (rhinorrhea) or ear (otorrhea), which is a sign of a basilar skull fracture (a linear fracture at the base of the brain). Other signs of basilar skull fracture include raccoon eyes (periorbital ecchymosis or bruising around the eyes) and Battle sign (bleeding and swelling behind the ear).

Be sure to evaluate the patient's pupillary light reflexes. An abnormal pupil reflex may result from increasing cerebral edema, which may indicate a life-threatening increase in ICP. Pupil size is normally 1.5 to 6 mm. Several signs to look for include ipsilateral miosis (Horner syndrome), in which one pupil is smaller than the other with a drooping eyelid; bilateral miosis, in which both pupils are pinpoint in size; ipsilateral mydriasis (Hutchinson pupil), in which one of the pupils is much larger than the other and is unreactive to light; bilateral midposition, in which both pupils are 4 to 5 mm and remain dilated and nonreactive to light; and bilateral mydriasis, in which both pupils are larger than 6 mm and nonreactive to light. Note the shape of the pupil as well because an oval pupil may indicate increased ICP and possible brain herniation. In more seriously injured patients, invasive ICP monitoring with an intraventricular catheter may be initiated for serial assessment of the ICP. Normally, ICP is 4 to 10 mm Hg, with an upper limit of 15 mm Hg. ICP is considered moderately elevated at levels of 15 to 30 mm Hg and severely elevated at levels above 30 mm Hg.

Psychosocial

Assess the patient's and family's ability to cope with a sudden illness and the change in roles that a sudden illness demands. Expect parents of children who are injured to be anxious, fearful, and sometimes guilt-ridden. Note if the injury was related to alcohol (approximately 40% to 60% of TBIs occur when the patient has been drinking), and elicit a drinking history from the patient or significant others.

Note that during the patient's recovery, subtle neurological deficits (such as subtle personality changes or inability to perform mathematical calculations) may exist long after hospital discharge and may interfere with the resumption of parenting, spousal, or occupational roles.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Computed tomography (CT) scan	Intact cerebral anatomy	Identification of size and location of site of injury or bleeding	Shows anterior to posterior slices of the brain to highlight abnormalities

Other Tests: Skull x-rays, magnetic resonance imaging, cervical spine x-rays, electrocardiogram, complete blood count, coagulation studies, serum chemistries, glucose test of any drainage suspected to be CSF using a reagent strip, alcohol and drug screening, lumbar puncture

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisAcute confusion related to cerebral tissue injury and swelling as evidenced by agitation, restlessness, changes in cognition, and/or misperception

Outcomes

OutcomesCognition; Concentration; Decision making; Information processing; Memory; Neurological status: Consciousness; Neurological status: Central motor control

Interventions

InterventionsCerebral perfusion promotion; Environmental management; Cerebral edema management; Medication management

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Management of airway, breathing, and circulation is important, and endotracheal intubation is necessary if the patient develops increased intracranial pressure. If a lesion identified by CT scan is causing a shift of intracranial contents or increased ICP, immediate surgical intervention is necessary. Endoscopic evacuation is being attempted as a very early stage treatment for intracerebral hemorrhage. A craniotomy may be performed to evacuate the ICH and ischemic tissue if the site is operable or to release ICP if viable tissue will be preserved. A ventriculostomy (creation of a hole within a cerebral ventricle for drainage) allows for external drainage for patients experiencing ventricular bleeding.

Ongoing monitoring and serial assessments are essential. ICP monitoring and sequential CT scanning may be needed in critically ill patients, and serial neurological assessments are needed on all patients to determine if ICP is increasing. Because bleeding and swelling can progress over several days after injury, the patient is monitored for deterioration even up to 10 days after injury. During periods of frequent assessment, the patient should not be sedated for longer than 30 minutes at a time; longer-acting sedation may mask neurological changes and place the patient at risk for lack of detection. Blood pressure needs to be regulated carefully, keeping the mean arterial pressure less than 130 mm Hg but avoiding hypotension so that the brain is adequately perfused. Fluid and electrolytes need careful adjustment to maintain brain perfusion but reduce the potential for cerebral edema. Hyperthermia contributes to stress on the brain and needs to be corrected as soon as possible.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Fentanyl (Sublimaze)	0.05 mg IV as needed	Short-acting opioid analgesic	Provides short-term (30 min) pain control and sedation without long-lasting effects that may mask neurological changes
Antihypertensives	Varies with drug	Labetalol, nicardipine	Reduce blood pressure to prevent worsening of ICH

Other Drugs: Some patients develop seizures as a complication and need anticonvulsants such as fosphenytoin. Drugs to reduce ICP, such as mannitol, may be used. Acetaminophen may be used to control fever. Phytonadione and protamine may be used to reverse coagulopathies, and famotidine may be used to prevent gastric ulcers.

Independent

After making sure the patient has adequate airway, breathing, and circulation, ongoing serial assessments of the patient's neurological responses are of highest priority. Timely notification of the trauma surgeon or neurosurgeon when a patient's assessment changes can save a patient's life. If the patient is intubated, make sure the endotracheal tube is anchored well. If the patient is at risk for self-extubation, maintain the patient in soft restraints. Notify the physician if the patient's Pao₂ drops below 80 mm Hg, if Paco₂ exceeds 40 mm Hg, or if severe hypocapnia (Paco₂< 25 mm Hg) occurs. Aspiration pneumonia is a risk and can occur even with endotracheal intubation. Elevate the head of the bed at 30 degrees to help prevent this complication.

Help control the patient's ICP. Maintain normothermia by avoiding body temperature elevations. Avoid flexing, extending, or rotating the patient's neck because these maneuvers limit venous drainage of the brain and thus raise ICP. Avoid hip flexion by maintaining the patient in a normal body alignment, limiting venous drainage. Maintain a quiet, restful environment with minimal stimulation; limit visitors as appropriate. Time nursing care activities carefully to limit prolonged ICP elevations. Use caution when suctioning the patient. Hyperventilate the patient beforehand and suction only as long as necessary. When turning the patient, prevent Valsalva maneuver by using a draw sheet to pull the patient up in bed. Instruct the patient not to hold on to the side rails. Monitor the blood pressure carefully to avoid hypertension and hypotension. Regulate fluids to maintain euvolemia (normal fluid balance) to support brain perfusion but to reduce the chance of elevated ICP.

Strategies to maximize the coping mechanisms of the patient and family are directed toward providing support and encouragement. Provide educational tools about TBIs. Teach the patient and family appropriate rehabilitative exercises, as appropriate. Help the patient cope with long stretches of immobility by providing diversionary activities that are appropriate to the patient's mental and physical abilities. TBI support groups may be helpful. Referrals to clinical nurse specialists, pastoral care staff, and social workers are helpful in developing strategies for support and education.

Help the significant others and family face the fear of death, disability, and dependency; involve the patient and the family in all aspects of care.

Evidence-Based Practice and Health Policy

Xue, M., & Yong, V. (2020). Neuroinflammation in intracerebral haemorrhage: Immunotherapies with potential for translation. The Lancet, 19, 1013–1032.

The authors suggest that current treatments for intracerebral hemorrhage are inadequate, and they aim to investigate literature on drugs that can reduce inflammation that can be neurotoxic. While the primary injury is serious and primarily mechanical, the secondary injury (occurs with swelling and biological changes in response to the primary injury) can lead to poor outcomes. The authors identified articles in electronic databases that discussed intracerebral hemorrhage and many terms associated with inflammation. They reviewed 10 clinical trials investigating drugs that reduced inflammation without interfering with the parts of inflammation that help with brain healing.
The studies were conducted in both humans and animals. The articles supported the use of minocycline, sphingosine-1-phosphate receptor modulators, and statins after a brain hemorrhage. They note that quick initiation of these drugs in high systemic doses might counteract the evolving secondary injury in people with intracerebral hemorrhage. The studies provide a promising way to improve outcomes.

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DRG Information ⬇

Introduction ⬆ ⬇