Update in intracerebral hemorrhage

Abstract

Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.

Keywords: diagnosis; intracerebral hemorrhage; prognosis; surgery; treatment.

Figure 1.

Intracerebral hemorrhage (ICH) classification and frequency based on hematoma location. Deep, 35% to 70%; lobar, 15% to 30%; cerebellum, 5% to 10%; and brain stem, 5% to 10%.

Figure 2.

Ganglionic or deep (A) versus lobar (B) ICH. A, Supratentorial, intracerebral (intraparenchymal) hemorrhage which originated within the right thalamus and extends into the right lateral ventricle. Etiology hypertension. B, Supratentorial right hemisphere large right lobar hematoma with mass effect, cerebral edema, and midline shift. Heterogeneous hematoma suggestive of blood in different stages. Etiology cerebral amyloid angiopathy. ICH indicates intracerebral hemorrhage.

Figure 3.

Atypical ICH case (hemorrhage and re-hemorrhage, lobar location) of a 57-year-old male presenting with complaints of headache with no history of hypertension. On examination, complete left homonymous hemianopsia was found. Computerized tomography showed a lobar hematoma in the right occipital lobe (A). Initial MR and conventional angiography (data not shown) failed to reveal neoplastic process, radiologic signs of CAA, or vascular malformation, respectively. Owing to the atypical radiologic presentation, a follow-up MRI was obtained 10 weeks later, showing a new rounded lesion surrounded by extensive edema in the right occipital lobe (B). Biopsy confirmed the diagnosis of melanoma. ICH indicates intracerebral hemorrhage; MRI, magnetic resonance imaging; CAA, cerebral amyloid angiopathy.

Figure 4.

Microbleeds gradient echo MRI showing multiple dark (hypointense) hemosiderin deposit within the basal ganglia bilaterally, as sometimes seen with chronic uncontrolled hypertension. Arrow pointing at microbleed located in the left glubus pallidus. MRI indicates magnetic resonance imaging.

Figure 5.

Diffuse areas or segmental arterial vasospasm (arrows) seen on MR angiography, affecting anterior and posterior circulation. MR indicates magnetic resonance.