Acute intracerebral haemorrhage: diagnosis and management

Abstract

Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.

Keywords: Stroke; clinical neurology.

Figure 1

Upper panel: Calculation of the intracerebral haemorrhage score, a clinical grading scale and a useful communication tool. Predicted 30-day case-fatality rates are derived from the original validation study; *a subsequent study in which early do-not-resuscitate orders were not placed observed 30% lower mortality rates. Lower panel: The use of the ABC/2 calculation (essentially the formula for the volume of an ellipsoid) to rapidly and accurately estimate the volume of an acute left-sided ganglio-capsular haemorrhage on non-contrast CT brain scan. (Copyright Iain McGurgan).

Figure 2

This axial non-contrast CT brain scan shows an acute large right parietal lobar haematoma, with moderately severe confluent low attenuation (leukoaraiosis) extending from the lateral ventricles into the subcortical white matter. (Copyright David Werring.)

Figure 3

Algorithm with risk stratification to aid decision-making on further imaging, and the diagnostic yield of intra-arterial digital subtraction angiography in ICH. CTA, CT angiography; DSA, digital subtraction angiography; ICH, intracerebral haemorrhage. ^¥Parameters for pre-test risk estimation are derived from scoring systems based on patient characteristics and non-contrast CT from the DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study, a prospective, multicentre study assessing the accuracy of multiple imaging modalities in the diagnosis of macrovascular causes of ICH. Individuals meeting the ‘low risk’ criteria above were excluded from the DIAGRAM study because of the low probability of finding an underlying macrovascular cause, and the yield of CTA in the remainder was 17%. Low rates of underlying macrovascular causes in this group were confirmed in a subsequent validation cohort. Primary intraventricular haemorrhage (ie, that with no discernible parenchymal component) has been added to the high-risk group, based on high detected rates of underlying macrovascular causes.^{39 ¶}Acute CTA should be performed within 2 days of CT, where possible. The diagnostic algorithm of the yield of intra-arterial DSA based on the CTA and clinical characteristics has been adapted from Wilson et al. MR/MR angiography performed acutely after a negative CTA may have additional value, particularly for the diagnosis of non-macrovascular causes, before considering intra-arterial DSA.³⁴ *Confluent leukoaraiosis (see fig ure 2) or lacunar infarction on acute CT brain scan.

Figure 4

Schema of the time course and mechanisms of secondary brain injury in intracerebral haemorrhage, including intraventricular haemorrhage.