3.1 Epidemiology

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  About 40 to 80% of ICH patients die within the first 30 days and half of all deaths occur within the first 48 hours. ¹

  
  
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  Incidence is 12 to 31 per 100,000 people and increases with age, doubling every 10 years after age 35. ^{2 , 3}

  
  
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  Occurs most in Asians followed by African Americans followed by Caucasians. ⁴

  
  
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  Risk factors include hypertension, age, alcohol intake, very low low-density lipoprotein (LDL) and cholesterol levels. ⁵

3.2 Etiologies/Differential Diagnosis

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  Hypertension is the most common cause

  
  
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  Cerebral amyloid angiopathy (in elderly, age >60 years)

  
  
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  Vascular malformations

  
  
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  Trauma

  
  
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  Coagulopathy

  
  
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  Aneurysm

  
  
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  Hemorrhagic transformation of infarction

  
  
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  Tumors

  
  
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  Neoplasm

  
  
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  Venous sinus thrombosis

  
  
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  Drugs—cocaine and appetite suppressants

3.3 Common Clinical Presentations

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  Headache, seizures, vomiting, worsening Glasgow coma score (GCS)

  
  
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  Neurologic deterioration can be gradual or rapid, depending on location and size of hemorrhage

  
  
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  Hypertensive hemorrhage tends to occur in the following locations (Fig. 3‑1)

  
  
  
  
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    Basal ganglia/thalamus > lobar > cerebellum > pons

    
    
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    Localizing symptoms

    
    
    
    
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      Basal ganglia/thalamus: hemisensory loss, hemiplegia, aphasia, homonymous hemianopsia, eye deviation toward the lesion but in rare cases have eye deviation away from lesion (“wrong way eyes”), upgaze palsy

      
      
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      Lobar seizures, homonymous hemianopsia, plegia or paresis more commonly in the leg than arm

      
      
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      Cerebellum ataxia, nystagmus, intractable vomiting, hydrocephalus

      
      
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      Pons pinpoint pupils, quadraparesis, coma, locked-in syndrome

  
  
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  Amyloid bleed is mostly lobar

  
  
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  Vascular malformations (cavernous malformation, arteriovenous malformation [AVM], dural arteriovenous fistula [dAVF]) can occur anywhere

3.4 Neuroimaging

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  Computed tomography (CT) of the head without contrast as soon as possible and then 24 hours after admission. If the patient is on anticoagulation more frequent imaging may be warranted (at 12 and 24 hours) while reversal of coagulopathy is in process.

  
  
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  CT angiography (CTA) of the head and neck is usually not indicated. However, in the following circumstances, a CTA may be helpful to rule out

  
  
  
  
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    Subarachnoid hemorrhage

    
    
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    AVM/Cavernous malformation

    
    
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    Hemorrhagic brain tumor

  
  
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  Fluid levels seen on CT scan indicate a coagulopathy

  
  
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  Volume assessment: ABC/2 estimate

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  Can use ABC/3 for hemorrhages secondary to warfarin

  
  
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  Magnetic resonance imaging (MRI) of brain with and without contrast to evaluate for underlying mass if no etiology is found (4–6 weeks post hemorrhage)

  
  
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  Appearance of hemorrhages on MRI (see Table 3‑1)