3 Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) occurs in 12 to 31 per 100,000 people each year in the United States, accounting for 10% of all strokes.1 It has the highest mortality rate among stroke types (30 to 50%).² The rate is expected to double in the next 50 years because of the increasing age of the population and the increased use of antithrombotic therapy. ICH is more common among men, the elderly, African Americans and Japanese, and people with low low-density lipoprotein (LDL) cholesterol. Hypertension is the major modifiable risk factor for ICH. Excessive alcohol consumption also markedly increases risk. Although clinical trials of specific interventions have been disappointing, rapid recognition and comprehensive management are essential to limiting mortality and long-term morbidity. Due to a variety of factors, estimates of in-hospital mortality have been halved over the past three decades.

History and Examination

History

• Assess for history of hypertension; check for blood pressure medications and noncompliance.
  
• Assess for history of cancer, smoking, weight loss, or tobacco use (metastatic disease).
  
• Assess for history of dementia (amyloid) or trauma. Check for history of vascular abnormalities (aneurysm, arteriovenous malformation [AVM], etc.).
  
• Alcohol or illicit drug use should be determined, as should use of warfarin, antiplatelet, or antithrombotic therapy.
  
• Liver disease, renal disease (uremic platelets), and hematologic disease history should be obtained.
  
• Decreased mental status is more common with ICH than ischemic stroke, and vomiting is more common with ICH than with either subarachnoid hemorrhage (SAH) or ischemic stroke.

Physical Examination

Note blood pressure (BP), evidence of head or other trauma.

Neurologic Examination

• A full neurologic examination, including assessment of mental status, cranial nerves, motor skills, and reflexes, as well as a sensory and cerebellar exam, should be performed on all patients.
  
• Review clues to localization of an ICH (Table 3.1).

Abbreviation: ICP, intracranial pressure.

Differential Diagnosis

1. Chronic hypertension. Common locations include basal ganglia (40 to 50%), lobar regions (20 to 50%), thalamus (10 to 15%), pons (5 to 12%), cerebellum (5 to 10%) (dentate nucleus is common for hypertensive ICH and vermis for coagulopathic ICH), and other brainstem sites (1 to 5%).
   
   
   
   • Related to rupture of Charcot-Bouchard microaneurysms, lipohyalinosis, and fibrinoid necrosis affecting penetrating arteries
     
   • Intraventricular hemorrhage (IVH) occurs in one-third of cases; commonly related to a thalamic or caudate ICH that ruptures into the ventricle
     
   • Clinical history of hypertension, especially uncontrolled, or eclampsia
     
   • Assess for left ventricular hypertrophy (LVH) on electrocardiogram (ECG) and hypertensive changes in retina or kidney.
   
   
2. Amyloid angiopathy
   
   
   
   • Age >60 years old
     
   • ß-amyloid deposition in small- and medium-sized arteries
     
   • Apo E2 and E4 alleles are more common with cerebral amyloid angiopathy-related ICH.
     
   • Lobar location, leukoariosis, multiple posteriorly located gradient echo signals on magnetic resonance imaging (MRI)
     
   • History of Alzheimer’s dementia
     
   • Multicompartmental bleeds (ICH + subdural hemorrhage SDH or ICH + SAH)
     
   • Recurrent ICH (recurrence rate up to 10% annually)
   
   
3. Coagulopathy
   
   
   
   • Clinical history, including warfarin use, hemophilia, or other clotting abnormality, liver or renal disease (uremic platelets)
     
   • Warfarin is a risk factor for ICH expansion, with expansion continuing longer than in patients not taking warfarin, and is associated with worse outcomes.
     
   • Multifocal bleeds more common
     
   • Cerebellar vermis location common
   
   
4. Arteriovenous malformation
   
   
   
   • Deep or superficial location
     
   • Flow voids on imaging studies
     
   • History of seizures or headaches
     
   • Absence of clinical history of hypertension or coagulopathy
     
   • Younger age
     
   • Initial bleeding rate is 2 to 4% per year; recurrent bleeding rate is 6 to 18% per year.3–5
     
   • Lifetime risk of hemorrhage is 105 minus patient’s age (in years).⁶
   
   
5. Cavernous angioma
   
   
   
   • Deep or superficial location
     
   • History of headaches or seizures
     
   • Frequently multiple “popcorn” gradient echo lesions on MRI with varying ages of blood
     
   • Angiographically occult (may see associated developmental venous anomaly)
     
   • Annual bleeding rate is 0.25 to 1.1% in the anterior circulation with a rebleeding rate of 4.5% per year. The annual bleeding rate for posterior fossa cavernous malformations is 2 to 3% with a 17 to 21% rebleeding rate.⁷
     
   • Genetics—KRIT-1 (CCM-1), CCM-2, PDCD-10 mutations
   
   
6. Cocaine, methamphetamine, or sympathomimetic drug use
   
7. Dural sinus thrombosis with hemorrhage
   
   
   
   • Seen in hypercoagulable states, dehydration, Crohn’s disease
     
   • Common cause of postpartum period ICH
     
   • Look for signs of elevated ICP; check opening pressure with lumbar puncture.
     
   • Requires full-dose anticoagulation, even with hemorrhage present8
   
   
8. Neoplasm
   
   
   
   • Most common primary tumors with hemorrhage—glioblastoma multiforme (GBM), oligodendroglioma, pituitary adenoma
     
   • Most common metastatic tumors with hemorrhage—lung, melanoma, thyroid, renal, choriocarcinoma
   
   
9. Vasculopathy
   
   
   
   • Rupture of small- or medium-sized arteries produces hemorrhage.
     
   • Typically preceded by weeks to months of headache, cognitive decline, psychiatric symptoms, and multiple strokes
     
   • May be associated with systemic illness (polyarteritis nodosa [PAN]; Wegener’s granulomatosis; Churg-Strauss syndrome; cryoglobulinemia; systemic lupus erythematosus [SLE]; rheumatoid arthritis; Sjögren’s syndrome; tuberculosis [TB]; bacterial, fungal, or viral vasculitis; hepatitis; herpes; selective serotonin reuptake inhibitors [SSRIs]; postpartum; Lyme disease; sarcoidosis; Behçet’s disease; syphilis; drug-induced [cocaine and methamphetamines] vasculopathy; sickle cell disease or carcinomatous vasculopathy) or limited to the central nervous system (Call-Fleming syndrome, primary CNS granulomatosis, lymphomatoid granulomatosis, MoyaMoya disease)
   
   
10. Ischemic stroke with hemorrhagic conversion
    
    
    
    • Underlying vascular territory lesion with petechial hemorrhage. Hemorrhagic infarction is typically heterogeneous and conforms to an arterial distribution. Primary ICH is homogeneous and does not necessarily conform to an arterial territory.
      
    • More common with embolic strokes with reperfusion
      
    • Occurs in 6% of patients after intravenous (IV) tissue plasminogen activator (tPA)⁹
    
    
11. Trauma
    
    
    
    • External evidence of trauma
      
    • Multifocal hemorrhages
      
    • Associated SDH, SAH, contusion, skull fracture

• Imaging studies
  
  
  
  • CT: Assess volume by A*B*C/2 method,10 assess location (deep, superficial, cerebellar, IVH), presence of hydrocephalus, midline shift (measured from septum pellucidum), or evidence of trauma (contusion, SAH); assess for AVM or underlying mass. CT scan remains the initial study of choice to distinguish infarction from ICH. Thirty-eight percent of patients will have a 33% increase in ICH size within 3 hours (two-thirds of cases will have expansion within 1 hour).¹¹ Increase in ICH volume is associated with early neurologic deterioration.¹² CT angiography may be useful for identifying an aneurysm or vascular malformation.
    
  • MRI is at least as sensitive for diagnosing ICH but more difficult to interpret because the appearance of ICH changes as blood products age.¹³ MRI (with contrast) is superior to CT for detecting underlying structural lesions (tumors, cavernous malformations, ischemic stroke), delineating edema, and identifying venous thrombosis (MR venography). MRI may not be feasible due to impaired consciousness, hemodynamic instability, pacemaker, or agitation. MRI with gadolinium should be considered in patients with a history of cancer or risk factors for cancer, no history of hypertension, or suspicious ICH location (i.e., lobar at the gray-white junction) (Table 3.2).
    
    
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