Intracerebral Haemorrhage

Essentials

• Intracerebral haemorrhage is the cause of ca. 15% of strokes.
• Hypertension is the most common cause of intracerebral haemorrhage, as it leads to changes at the walls of small cerebral blood vessels.
• Good management of hypertension is an essential part of both primary and secondary prevention.

Epidemiology

• The incidence has reduced as the result of improved management of hypertension although in the oldest age groups the incidence is growing.
• Acute phase mortality is higher in intracerebral haemorrhage than in cerebral infarction.

Aetiology

• Hypertension-associated intracerebral haemorrhage (ICH) is the most common form.
  • Located typically in the area of the basal ganglia and thalamus, cerebellum or the brainstem.
  • Usually leads to massive hemiparesis and impaired consciousness.
  • The bleed may also occur within the cerebrospinal fluid space.
• Other underlying causes of ICH include cerebral amyloid angiopathy, cavernous haemangioma, arteriovenous malformation, cerebral arterial vasculitis or vasoconstriction, malignant brain tumours and brain metastases.
  • An unusual location of the haemorrhage and the absence of hypertension suggest these causes.
  • The structural background cause is not always identifiable on the CT scan taken at the acute phase due to the large quantity of blood present. An MRI scan or CT angiography is usually diagnostic at the latest after a few months.
  • In addition to subarachnoid haemorrhage, cerebral arterial aneurysms may also cause ICH.
  • Sinus thrombosis should be considered in differential diagnosis. For other causes of blood in the cerebrospinal fluid, see Intracranial Aneurysm and Subarachnoid Haemorrhage (Sah).
• Precipitating factors for ICH include traumas, excessive use of alcohol, use of illegal drugs, anticoagulant drug therapy, hepatic insufficiency or other coagulopathy.

Symptoms

• Rapidly progressive hemiplegia which may be associated with impaired consciousness, vomiting or seizure with associated unconsciousness.
• The neurological signs and symptoms are the same as seen in cerebral infarction and are dependent on the site and extent of the bleed. In intracerebral haemorrhage, however, the initial clinical picture is more often progressive than in cerebral infarction, and an increase in blood pressure is typical.
  • In at least 50% of patients, the bleeding will continue during the first 24 hours and most strongly already during the first hours.
• If the haemorrhage is extensive or located in the brainstem or cerebellum, there is a risk of increased intracranial pressureIncreased Intracranial Pressure.
  • Cerebellar haemorrhage: dizziness, vomiting, limb or truncal ataxia, as well as nystagmus and other disturbances in eye movements are the most common symptoms. The level of consciousness may deteriorate and respiratory arrest may develop, both unexpectedly, even in a patient with few symptoms during the first days due to sudden disturbance in the flow of the cerebrospinal fluid.
  • Symptoms typical for haemorrhage in the brain stem include disturbances in consciousness and different brain stem symptoms, including sensation and paralysis symptoms of the limbs.

Diagnosis and treatment Haemostatic Therapies for Acute Spontaneous Intracerebral Haemorrhage

Neurosurgical management

• A neurosurgeon should always be consulted concerning a patient with intracerebral haemorrhage who is in active treatment, if the condition of the patient worsens.
• In a cerebellar haemorrhage that is associated with decreased level of consciousness, operative treatment may be life-saving and lead to good recovery Surgery for Primary Supratentorial Intracerebral Haemorrhage.
• In an intracerebral haemorrhage of a cerebral hemisphere, the benefit of surgery has not been proven, but if the patient's condition worsens, surgery may be life-saving.