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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

  • All previous self-caring patients should be treated at a stroke or neurological unit.
  • CT scan of the head and, if needed, CT angiography of the cerebral arteries is the diagnostic investigation of choice.
  • The treatment of a patient with intracerebral haemorrhage differs little from that of a patient with cerebral infarction, see Cerebral Infarction (Ischaemic Stroke). The patient is kept at bed rest during the acute phase. Anticoagulation and any other bleeding tendencies must be reversed if there are chances for recovery.
  • Managing blood pressure in the acute phase takes place at discretion and lacks standard procedures. It is carried out with intravenous drugs during the first days according to local treatment guidelines. According to a European guideline, reducing blood pressure at the acute phase may be indicated, if the systolic pressure is over 140 mmHg. A large and sudden decrease in blood pressure should, however, be avoided.
  • Epileptic seizures in the acute phase are treated primarily by intravenous antiepileptic drugs.
  • Thrombosis prophylaxis is carried out with intermittent pneumatic compression stockings until adequate mobilization of the patient takes place.
    • The use should be started at the latest 12 hours after the beginning of immobilization; otherwise ultrasonography of the lower extremity veins should be done before using the stockings.
    • If the stockings cannot be used, if the risk of a bleeding complication is small or if the patient is known to be, in addition to being immobilized, in a prothrombotic state, starting subcutaneous low-molecular weight heparin (LMWH) Antithrombotic Treatment after Stroke Due to Intracerebral Haemorrhage should be considered.
    • LMWH is started not earlier than after 24 hours, after the head CT control. Dosage: enoxaparin 20 mg subcutaneously twice daily or deltaparin 2 500 IU subcutaneously once daily.
  • Any decision regarding DNR (do not resuscitate) should be postponed until at least the second day of treatment.
    • If the patient has no chances of survival, the possibility of donating organs should be kept in mind. The majority of organ donors have succumbed to an intracerebral haemorrhage.
  • Rehabilitation should be started in the initial phase, even as early as the second day of treatment. For rehabilitation of a stroke patient, see Rehabilitation of a Patient with Cerebrovascular Disorder.
  • The risk of recurrent bleeding is decreased by effective treatment of hypertension.
  • In the early phase of intracerebral haemorrhage the mortality rate is high, but the prognosis of surviving patients is equal to that of patients with cerebral infarction.

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.

    References

    • Steiner T, Al-Shahi Salman R, Beer R et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014;9(7):840-55. [PubMed]
    • Lioutas VA, Beiser AS, Aparicio HJ et al. Assessment of Incidence and Risk Factors of Intracerebral Hemorrhage Among Participants in the Framingham Heart Study Between 1948 and 2016. JAMA Neurol 2020;77(10):1252-1260. [PubMed]