AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Background

The terms intracerebral hemorrhage (ICH) and hemorrhagic stroke are used interchangeably in this discussion and are regarded as a separate entity from hemorrhagic transformation of ischemic stroke. ICH accounts for 10-15% of all strokes and is associated with higher mortality rates than cerebral infarctions. Patients with hemorrhagic stroke present with similar focal neurologic deficits but tend to be more ill than patients with ischemic stroke. Patients with intracerebral bleeds are more likely to have headache, altered mental status, seizures, nausea and vomiting, and/or marked hypertension; however, none of these findings distinguish reliably between hemorrhagic and ischemic strokes.

Pathophysiology

In ICH, bleeding occurs directly into the brain parenchyma. The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension. Other mechanisms include bleeding diatheses, iatrogenic anticoagulation, cerebral amyloidosis, and cocaine abuse. ICH has a predilection for certain sites in the brain, including the thalamus, putamen, cerebellum, and brain stem. In addition to the area of the brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by the mass effect of the hematoma. A general increase in intracranial pressure may occur.

Frequency

United States

ICH accounts for 10-15% of all strokes. Recent reports indicate an incidence exceeding 500,000 new strokes of all types per year.

Mortality/Morbidity

• Stroke is a leading killer and disabler. Combining all types of stroke, it is the third leading cause of death and the first leading cause of disability.
• Morbidity is more severe and mortality rates are higher for hemorrhagic stroke than for ischemic stroke. Only 20% of patients regain functional independence.
• The 30-day mortality rate for hemorrhagic stroke is 40-80%. Approximately 50% of all deaths occur within the first 48 hours.

Race

African Americans have a higher incidence of hemorrhagic and ischemic strokes than other races in the United States. The incidence of hemorrhagic stroke in the Japanese population is increased.

Age

The risk of stroke increases with age.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

History

• Patients' symptoms vary depending on the area of the brain affected and the extent of the bleeding.
• Hemorrhagic strokes are more likely to exhibit symptoms of increased intracranial pressure than other types of stroke.
• • Headache, often severe and sudden onset
  • Nausea and/or vomiting
• Seizures are more common in hemorrhagic stroke than in ischemic stroke. They occur in up to 28% of hemorrhagic strokes and generally occur at the onset of the ICH or within the first 24 hours.

Physical

• Intracerebral hemorrhage (ICH) may be clinically indistinguishable from ischemic stroke.
• Hypertension commonly is a prominent finding.
• An altered level of consciousness or coma is more common with hemorrhagic strokes than with ischemic strokes. Often, this is due to an increase in intracranial pressure.
• Meningismus may result from blood in the ventricles.
• Focal neurologic deficits
• • The type of deficit depends upon the area of brain involved.
  • If the dominant hemisphere (usually left) is involved, a syndrome consisting of right hemiparesis, right hemisensory loss, left gaze preference, right visual field cut, and aphasia may result.
  • If the nondominant (usually right) hemisphere is involved, a syndrome of left hemiparesis, left hemisensory loss, right gaze preference, and left visual field cut may result. Nondominant hemisphere syndrome also may result in neglect when the patient has a left-sided hemi-inattention and ignores the left side.
  • If the cerebellum is involved, the patient is at high risk of herniation and brainstem compression. Herniation may cause a rapid decrease in the level of consciousness, apnea, and death.
  • Other signs of cerebellar or brainstem involvement include the following:
    • Gait or limb ataxia
    • Vertigo or tinnitus
    • Nausea and vomiting
    • Hemiparesis or quadriparesis
    • Hemisensory loss or sensory loss of all 4 limbs
    • Eye movement abnormalities resulting in diplopia or nystagmus
    • Oropharyngeal weakness or dysphagia
    • Crossed signs (ipsilateral face and contralateral body)
  • Many other stroke syndromes are associated with ICH, ranging from mild headache to neurologic devastation. At times, a cerebral hemorrhage may present as a new-onset seizure.

Causes

• Hypertension (up to 60% of cases)
• Advanced age (risk factor)
• Cerebral amyloidosis (affects people who are elderly and may cause up to 10% of ICHs)
• Coagulopathies (eg, due to underlying systemic disorders such as bleeding diathesis or liver disease)
• Anticoagulant therapy
• Thrombolytic therapy for acute myocardial infarction (MI) and acute ischemic stroke (can cause iatrogenic hemorrhagic stroke)
• Abuse of cocaine and other sympathomimetic drugs
• Arteriovenous malformation
• Intracranial aneurysm
• Vasculitis
• Intracranial neoplasm
• History of prior stroke (risk factor)

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Other Problems to be Considered

Postictal (Todd) paralysis
Hyperosmolality

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Lab Studies

• Complete blood count
• Coagulation profile
• Electrolytes
• Serum glucose
• Blood type and screen

Imaging Studies

• Brain imaging
• • Brain imaging is a crucial step in a patient's evaluation.
  • It must be obtained on an emergent basis.
  • Brain imaging aids in making the diagnosis of hemorrhage.
  • It may identify complications including intraventricular hemorrhage, brain edema, or hydrocephalus.
  • Either noncontrast CT or MRI of the brain are the modalities of choice.
  • Noncontrast CT of the brain
  • • Noncontrast CT differentiates hemorrhagic stroke from ischemic stroke.
    • It is useful in distinguishing stroke from other intracranial pathology.
    • It can identify virtually all intracerebral hematomas greater than 1 cm in diameter.
  • MRI
• • • In the past, noncontrast CT was the criterion standard for diagnosing hemorrhagic stroke. Recent progress has demonstrated that current MRI techniques are capable of accurately diagnosing hemorrhagic stroke.
    • MRI, especially newer techniques such as diffusion-weighted imaging, has been shown to identify ischemic stroke earlier and more reliably than CT scanning. MRI is being used with increasing frequency in the evaluation of ischemic stroke.
    • MRI may identify an underlying vascular malformation or lesion that caused the bleeding.
  • Head CT should be obtained in patients with contraindications to MRI.

• Chest radiography should be obtained to screen for comorbid conditions.

Other Tests

• Obtain an electrocardiogram (ECG) and begin cardiac monitoring. Cardiac dysrhythmias and myocardial ischemia have a significant coincidence with stroke.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Prehospital Care

• Identify and address, as clinically indicated, any compromise of ABCs.
• Recognize signs and symptoms of stroke.
• Notify the receiving hospital.
• Rapid transport to the closest facility capable of providing appropriate stroke care (if applicable).
• In general, do not treat elevations of blood pressure (BP) in the field.

Emergency Department Care

• Assess ABCs. Address any compromise in patient's status as clinically indicated.
• Establish intravenous (IV) access.
• Obtain bedside glucose determination.
• • Hypoglycemia may mimic stroke.
  • Hyperglycemia has been associated with poorer outcomes in stroke patients.
• Institute cardiac monitoring and obtain an ECG.
• The role of prophylactic anticonvulsant therapy has not been clearly defined. A brief period of anticonvulsant therapy soon after hemorrhagic stroke onset may reduce the risk of early seizures in patients with lobar hemorrhage. Phenytoin in conventional doses is commonly used.
• Careful blood pressure (BP) monitoring is important.
• • No controlled studies define optimum BP levels.
  • Greatly elevated BP is thought to lead to rebleeding and hematoma expansion.
  • Patients who have had a stroke may lose their cerebral autoregulation of cerebral perfusion pressure.
  • Although BP elevations may risk further hemorrhage, too rapid or aggressive BP lowering may compromise cerebral perfusion.
  • The American Heart Association guidelines for treating elevated BP are as follows:
  • • (1) If systolic BP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of BP with continuous intravenous infusion with frequent BP (q5min) checks.
    • (2) If systolic BP is >180 mm Hg or MAP is >130 mm Hg and there is evidence or suspicion of elevated ICP, then consider monitoring of ICP and reducing blood pressure using intermittent or continuous intravenous medications to maintain cerebral perfusion pressure >60-80 mm Hg.
    • 3) If systolic BP is >180 or MAP is >130 mm Hg and there is NOT evidence or suspicion of elevated ICP, then consider modest reduction of BP (target MAP of 110 mm Hg or target BP of 160/90 mm Hg) with BP checks every 15 minutes.

• Intubation should be performed for patients who demonstrate potential loss of airway protective mechanisms or signs of brainstem dysfunction. If intubation is needed, rapid sequence intubation should be performed with technique and medications aimed at limiting any increase in intracranial pressure.
• Currently, no effective targeted therapy for hemorrhagic stroke exists. Much interest has been generated to determine if treatment with hemostatic therapy may be effective. A preliminary study of treatment with recombinant factor VIIa demonstrated reduced mortality and improved functional outcomes. However, unfortunately, the results of the larger randomized trial revealed no overall benefit of treatment. Further studies are necessary to develop other potential treatment options.
• Patients on warfarin with elevated international normalized ratio (INR) must be treated to lower the INR to prevent hematoma expansion. Treatment options include vitamin K and administration of clotting factors, including fresh frozen plasma (FFP), prothrombin complex concentrates (PCC), and recombinant factor VIIa.

Consultations

• Emergent neurosurgical or neurological consultation often is indicated; local referral patterns may vary.
• • A potential treatment of hemorrhagic stroke is surgical evacuation of the hematoma. The role of surgical treatment for supratentorial intracranial hemorrhage remains controversial. Outcomes in published studies are conflicting. A published meta-analysis of studies suggested some promise for early surgical intervention. However, a recent study comparing early surgery versus initial conservative treatment failed to demonstrate a benefit with surgery.
  • Surgical intervention for cerebellar hematoma has been shown to improve outcome. It can be lifesaving in the prevention of brainstem compression.
  • Need for invasive intracranial pressure monitoring should be assessed by the neurosurgeon.
  • Need for emergent cerebral angiography should be assessed by the neurosurgeon. Patients with no clear cause of the hemorrhage and who would otherwise be candidates for surgery should be considered for angiographic evaluation.

FOLLOW-UP

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• ICU admission is mandatory.
• • Monitor for airway compromise.
  • Monitor and carefully address the patient's BP.
  • Reassess neurologic status frequently.
  • Monitor cardiovascular status continuously.
  • Select patients may require intracranial pressure monitoring.
  • Select patients may require intraventricular catheterization for hydrocephalus.

Transfer

• Patients with ICH should be considered for transfer to a facility with neurosurgical capabilities.

Complications

• Increased intracranial pressure and herniation are the dreaded complications. Worsening cerebral edema is often implicated in neurologic deterioration in the first 24-48 hours.
• Early hemorrhage growth is associated with neurologic deterioration. Expansion of the hematoma is the most common cause of neurologic deterioration in the first 3 hours.
• In patients who are initially alert, 25% will have a decrease in consciousness within the first 24 hours.
• Post-stroke seizures may develop.
• Stroke is the leading cause of permanent disability.

Prognosis

• The prognosis varies depending on the severity of stroke and the location and the size of the hemorrhage.
• Lower Glasgow coma scores are associated with poorer prognosis and higher mortality.
• A larger volume of blood at presentation is associated with a poorer prognosis.
• Growth of the hematoma volume is associated with a poorer functional outcome and increased mortality. 
• The presence of blood in the ventricles is associated with a higher mortality rate. In one study, the presence of intraventricular blood at presentation was associated with more than a 2-fold increase in death.
• Patients with oral anticoagulation–associated intracerebral hemorrhage have higher rates of mortality and poorer functional outcomes.
• Other complicating medical comorbidities also affect the prognosis.

Patient Education

• For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Stroke.

MISCELLANEOUS

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to recognize potential stroke and obtain brain imaging
• Failure to consult with a neurologist/neurosurgeon
• Failure to transfer to a facility with neurosurgical capabilities
• Failure to reverse anticoagulated state

ACKNOWLEDGMENTS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, to the development and writing of this article.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

Media file 1:  Large intracerebral hemorrhage with midline shift.
	View Full Size Image
Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• MISCELLANEOUS
• Acknowledgments
• Multimedia
• References

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Article Last Updated: Feb 5, 2008