The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Abstract

Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.

Fig. 1

Principles of ICH management. GCS Glasgow Coma Scale, SaO2 Oxygen arterial saturation, PaCO2 partial pressure of carbon dyoxide, ICP intracranial pressure, CBC Complete Blood Count, PTT Partial Thromboplastin Time, INR international normalised ratio, VKAs Vitamin K inhibitors, NOACs newer oral anticoagulants, LMWH lower molecular weight heparin, HTN hypertension, NCCT non contrast computed tomography, CTA computed tomography angiography, MRI magnetic resonance imaging, MRA Magnetic Resonance Angiography, MRV Magnetic Resonance Venogram, DSA digital subtraction angiography, ICH intracerebral hemorrhage, IVH intraventricular hemorrhage, NIHSS National Institutes of Health Stroke Scale, SBP systolic blood pressure, EVD external ventricular drain

Fig. 2

Deep intracranial hemorrhage. Common locations of hypertensive hemorrhage (clockwise: putamen, thalamus, cerebellum, and pons)

Fig. 3

Spot sign. Initially described as contrast extravasation on CTA, the term has evolved to encompass foci of enhancement within the hematoma on CTA (red arrow)