Intracerebral Haemorrhage (ICH)

Overview

Intracerebral haemorrhage (ICH) is a life-threatening type of stroke Opens in new window, caused by bleeding within the brain tissue itself. A stroke occurs when the brain is deprived of oxygen and blood supply.

An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep hemorrhages can expand into the ventricles – the fluid filled spaces in the center of the brain. Blockage of the normal cerebrospinal (CSF) circulation can enlarge the ventricles (hydrocephalus) resulting in these symptoms:

• headache, nausea, and vomiting
• lethargy or confusion
• sudden weakness or numbness of the face, arm or leg, usually on one side
• loss of consciousness
• temporary loss of vision
• seizures

Primary ICH is most commonly caused by long-standing hypertension induced small vessel disease. The site of hypertensive haemorrhage tends to occur in characteristic locations such as the basal ganglia, thalamus and cerebellum. Berry aneurysms most commonly arise around the Circle of Willis, hence ICH due to aneurismal rupture is often located around this area.

Secondary ICH may occur into an underlying lesion such as a tumor or infarct, and clinical deterioration may result — so called symptomatic ICH (SICH) — but this is not always the case.

The clinical presentation of primary ICH is typically of sudden onset of a neurologic deficit with associated headache, collapse/transient loss of consciousness, hypertension and vomiting. However, clinical features alone are unable to differentiate ICH from infarction, hence the requirement for brain imaging to confirm the diagnosis. Both CT and MRI (Using gradient echo sequences) are equivalent in the detection of ICH.

Medical Management

Primary ICH is a medical emergency with a high mortality of between 35% and 50%, with half of these deaths occurring in the first 2 days. There is also a very high risk of dependency. Haematomas can expand rapidly, and there is a significant risk of early neurological deterioration and increasing intracranial pressure (ICP).

Treatment of raised ICP in a setting of ICH involves a range of modalities similar to those used in head trauma. These include elevation of the head of the bed, analgesia, sedation, an osmotic diuretic such as mannitol and hypertonic saline, hyperventilation, drainage of CSF via ventricular catheter, and neuromuscular paralysis.

There is no good evidence regarding the management of hypertension in the setting of ICH sufficient to make firm recommendations. Guidelines have been published, but treatment should be individualized and take place in consultation with neurology/neurosurgery/intensive care specialists. Sudden falls in blood pressure and hypotension should be avoided, as they may aggravate cerebral ischaemia in the setting of raised ICP, which is often associated with ICH.

Early studies of the use of recombinant factor Vlla have shown promise when administered within 3 hours of stroke onset, showing a significant reduction in haematoma expansion and improved mortality. Steroids are not indicated in ICH. Anticonvulsant prohylaxis is common practice.

Management of ICH associated with anticoagulation or thrombolysis is a matter of urgency and should be done in consultation with a haematologist and a neurosurgeon. Agents such as protamine sulphat, vitamin K, prothrombin complex concentrate and FFP may be indicated. Factor Vlla normalizes the INR very rapidly, but with a greater potential for thromboembolism.

Surgical Management

Surgical management of ICH depends on the location, cause, neurological deficit and overall clinical state. Early neurosurgical consultation should be obtained. High level evidence for improved outcomes following drainage of supratentorial haematomas by craniotomy is lacking, but the procedure may be indicated in selected patients, particularly in those with lobar clots within 1 cm of the surface. In patients presenting in coma with deep haemorrhages, craniotomy is not recommended and may worsen outcomes. The presence of a cerebellar haematoma is a particular indication for surgery, with a potential for a good neurological recovery. A variety of other techniques, such as minimally invasive haematoma evacuation, are under investigation.