Nontraumatic intracranial hemorrhage

Epidemiology

  • 20% of all stroke events
  • 10-15% of all first-time stroke events
  • 20-30% of all patients with spontaneous ICH die within the first 48 hours from onset
  • 1 year mortality is almost 60%
  • 80% of patients who survive have significant residual neurologic deficit
  • In at least 33% of cases the hematoma enlarges within the first 3 hours from onset

Risk factors

  • Age: incidence is significantly higher after 55 and doubles every decade until 80
  • Gender: more common in men
  • Race: more common in blacks (and probably also Asians) than whites
  • Previous stroke increases risk for spontaneous ICH up to 23:1
  • Chronic alcohol consumption is an independent risk factor
  • Smoking probably does not increase risk for spontaneous ICH even though it increases risk for ischemic stroke and subarachnoidal hemorrhage
  • Cocaine, amphetamines, phencyclidine and sympathomimetics, among others
  • Use of antithrombotics or thrombolytic treatment
  • Hypertension
  • Arteriopathy (notably: amyloid angiopathy, arteritides, lipohyalinosis)
  • Vascular abnormalities (notably: AVM, cavernoma)
  • Primary or secondary coagulation disorder (hemophilia, thrombocytopenia, leukemia, etc)
  • CNS infection (especially fungal, granulomas and HSV encephalitis)
  • Trauma: ICH may be a delayed post-traumatic complication. Most appear within 72 hours from trauma
  • Pregnancy: risk is higher up to 6 weeks post partum
  • Craniotomy or carotid endarterectomy
  • Malignant tumors. Most commonly associated with ICH:
    1. Glioblastoma
    2. Lymphoma
    3. Melanoma
    4. Choriocarcinoma
    5. Renal cell carcinoma
    6. Bronchogenic carcinoma (low frequency of ICH but high prevalence)

Location

In descending order of frequency:

  • Putamen 60-65%
  • Thalamus 15-25%
  • Pons 10%
  • Cerebellum 10%
  • Lobar 5-10%

Management guidelines

The points below are only suggested as a guide. No general evidence-based guidelines exist at this time.

  • Assess and secure Airway, Breathing, Circulation
  • Monitor patient in an ICU or specialized stroke unit
  • Maintain normothermia
  • Maintain euglycemia
  • Consider ICP monitoring if persistently increased ICP. Use mannitol and furosemide appropriately
  • Maintain MAP <130mmHg in patients with a history of hypertension
  • Maintain cerebral perfusion pressure (MAP-ICP) >70mmHg
  • Indications for ventriculostomy:
    1. Acute hydrocephalus
    2. Intraventricular hematoma extension causing obstruction of 3rd ventricle
    3. ICP management
  • Monitor for electrolyte and plasma osmolality disorders, especially if mannitol and furosemide are used. Watch for SIADH
  • Consider prophylactic AEDs in patients with lobar hemorrhages
  • Reverse anticoagulant effect
  • Patients on antiplatelet drugs or thrombocytopenia with counts <75000 should receive platelets. Maintain a platelet count >75000 and if possible >100000
  • Recombinant activated coagulation factor VII (rFVIIa) may be beneficial if administered within the first 4 hours
  • Indication for surgical evacuation is controversial and no clear criteria exist. The decision for evacuation should be individualized



References

  • Spontaneous Intracerebral Hemorrhage Emerg Med Clin North Am. 2017 Nov;35(4):825-845. doi: 10.1016/j.emc.2017.07.002
  • Management of spontaneous nontraumatic intracranial hemorrhage J Pharm Pract. 2010 Oct;23(5):398-407. doi: 10.1177/0897190010372320
  • The critical care management of spontaneous intracranial hemorrhage: a contemporary review Crit Care. 2016 Sep 18:20:272. doi: 10.1186/s13054-016-1432-0
  • Nontraumatic intracranial hemorrhage Neuroimaging Clin N Am. 2010 Nov;20(4):469-92. doi: 10.1016/j.nic.2010.07.003
  • Recommendations for the management of intracranial haemorrhage–part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis. 2006;22(4):294–316. doi: 10.1159/000094831