3 Cerebrovascular Emergency: Spontaneous Intracerebral Hemorrhage (ICH)
Abstract
Spontaneous ICH remains a significant cause of morbidity and mortality throughout the world. The aim of this chapter is to provide the etiology, presentation, and treatment of this disease.
Keywords: ICH, hemorrhage, hypertension, amyloid, reversal
3.1 Epidemiology
• 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
• Incidence is 12 to 31 per 100,000 people and increases with age, doubling every 10 years after age 35.2,3
• Occurs most in Asians followed by African Americans followed by Caucasians.4
• Risk factors include hypertension, age, alcohol intake, very low low-density lipoprotein (LDL) and cholesterol levels.5
3.2 Etiologies/Differential Diagnosis
• Hypertension is the most common cause
• Cerebral amyloid angiopathy (in elderly, age > 60 years)
• Vascular malformations
• Trauma
• Coagulopathy
• Aneurysm
• Hemorrhagic transformation of infarction
• Tumors
• Neoplasm
• Venous sinus thrombosis
• Drugs—cocaine and appetite suppressants
3.3 Common Clinical Presentations
• Headache, seizures, vomiting, worsening Glasgow coma score (GCS)
• Neurologic deterioration can be gradual or rapid, depending on location and size of hemorrhage
• Hypertensive hemorrhage tends to occur in the following locations (▶ Fig. 3.1)
◦ Basal ganglia/thalamus > lobar > cerebellum > pons
◦ Localizing symptoms
– 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
– Lobar: seizures, homonymous hemianopsia, plegia or paresis more commonly in the leg than arm
– Cerebellum: ataxia, nystagmus, intractable vomiting, hydrocephalus
– Pons: pinpoint pupils, quadraparesis, coma, locked-in syndrome
• Amyloid bleed is mostly lobar
• Vascular malformations (cavernous malformation, arteriovenous malformation [AVM], dural arteriovenous fistula [dAVF]) can occur anywhere
Fig. 3.1 (a) Basal ganglia hemorrhage due to hypertension. (b) Pontine hemorrhage from hypertension or cavernous malformation. (c) Right frontal hemorrhage due to amyloid angiopathy. (d) Left hemispheric hemorrhage from anticoagulation.
3.4 Neuroimaging
• 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.
• 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
◦ Subarachnoid hemorrhage
◦ AVM/Cavernous malformation
◦ Hemorrhagic brain tumor
• Fluid levels seen on CT scan indicate a coagulopathy
• Volume assessment: ABC/2 estimate
• Can use ABC/3 for hemorrhages secondary to warfarin
• 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)
• Appearance of hemorrhages on MRI (see ▶ Table 3.1)
3.5 Treatment
• Blood pressure (BP) (see ▶ Fig. 3.2).
◦ Elevated BP is associated with hematoma expansion, neurologic deterioration, and death and dependency.6 Early control is essential.
Fig. 3.2 Thomas Jefferson University algorithm for the management of hypertensive emergency in patients with hemorrhagic stroke.
◦ Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) and Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage (INTERACT) found reduction of systolic blood pressure (SBP) < 140 to be safe.7,8
◦ INTERACT2 showed no increase in death or serious adverse events from early intensive BP lowering.9
◦ For ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe and can be effective for improving functional outcome.6
3.5.1 Aggressive Reduction in SBP to Goal of 140
• Place arterial line and peripheral intravenous (IV) medications
• Use continuous IV medications
◦ Clevidipine, 4 to 6 mg/hour (start 1–2 mg/hour)
◦ Labetalol, 2 mg/min (max 300 mg per day)
◦ Nicardipine, 5 to 15 mg/hour (start 5 mg/hour)
3.5.2 Seizures
• Frequency of clinical seizures within 1 week of ICH is 16%, with majority occurring at onset.10
• Clinical seizures should be treated with IV antiepileptics.
• Continuous electroencephalography (EEG) monitoring for those with depressed mental status that is out of proportion to injury.
• Prophylactic antiepileptic medication is not recommended.6
3.5.3 Intracranial Pressure
See Chapter 6.
3.5.4 Medical Issues
• Hypoglycemia and hyperglycemia should be avoided.
• Goal normothermia should be achieved.
• After documentation of cessation of bleeding, subcutaneous heparin should be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset.6
◦ At Thomas Jefferson University we routinely start subcutaneous heparin 24 to 48 hours after onset of hemorrhage after a repeat stable CT scan.
3.5.5 Coagulopathies
Reversing anticoagulant or antiplatelet agents is often necessary to minimize rebleeding or prevent bleeding when surgical procedures are required emergently. See ▶ Table 3.2 and ▶ Fig. 3.3 for details of specific reversal agents.
3.5.6 Surgical Options
• Intraventricular tPA
• Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR-IVH) trial demonstrated that intraventricular administration of tPA reduced intracranial pressure (ICP), lowered external ventricular drain (EVD) obstructions, and shortened duration of EVD but mortality and mRS (modified Rankin Scale) were not different.11
• Phase 3 randomized CLEAR III trial is in progress.
• Efficacy and safety of this treatment remains uncertain.6
3.5.7 Craniotomy
• The International Surgical Trial in Intracerebral Hemorrhage (STICH) found no overall statistically significant difference in mortality or functional outcome for patients who underwent early surgery.12
◦ Subgroup analysis suggested that patients with lobar hemorrhages within 1 cm of the cortex might benefit from surgery.
• STICH II trial showed no benefit for patients with superficial lobar hemorrhages within 1 cm of the cortex and without IVH.13
• An updated analysis showed advantage for surgery when all patients were considered, but there was significant heterogeneity in the data.
• Patients with cerebellar ICH who deteriorate neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible.6
◦ Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended.
• For most patients with supratentorial ICH, the usefulness of surgery is not well established.6
◦ Consider in deteriorating patients for life-saving measures.
3.5.8 Craniectomy
• No large randomized controlled trials
• Might reduce mortality for patients who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management6
