Intracerebral haemorrhage

Pathophysiology

Bleeding into the brain parenchyma itself (as opposed to SAH, SDH or extra-dural). Most are either:

50% occur in basal ganglia or internal capsule (same distribution of vascular anatomy as lacunar strokes), but can be cortical/cerebellar.

Haemorrhage/clot volume and associated oedema contribute to raised ICP, which can then cause ischaemic injury, and herniation.

Epidemiology

  • 10-15% of first-time strokes in USA/Western Europe (11% in UK)
  • 25% of first-time strokes in Japanese populations
  • HTN-associated ICH has decreased as HTN control has improved
  • ICH has increased in older cohorts linked to increasing use of anti-thrombotics and CAA [ref]
  • Risk factors include cocaine/amphetamine use, and recent heavy alcohol consumption.

Symptoms/signs

  • Putamen – hemiplegia/sensory loss, homonymous hemianopia, gaze palsy, low GCS
  • Thalamus – hemiplegia/sensory loss, extension to upper brainstem causes vertical gaze palsy, horizontal gaze palsy can develop – deviates towards hemiplegia (cortical stroke gaze deviate away from hemiplegia)
  • Cerebellar – ataxia, vomiting, occipital headache, and facial weakness, stupor as brainstem compresses
  • Pons – coma, tetraplegia, pinpoint pupils. If awake, facial weakness, deafness, and dysarthria
  • Lobar (commonly parietal/occipital lobes, associated with CAA) – seizures, homonymous hemianopia
  • Worsening deficits over minutes-hours (as opposed to immediate onset and worst at onset in SAH)
  • Headache, vomiting, low GCS as haemorrhage expands
  • Meningism if intraventricular haemorrhage/associated SAH
  • Intraventricular haemorrhage may cause secondary hydrocephalus

Diagnosis

Non-contrast CT head. Taken from Dastur & Yu 2017

Non-contrast CT head demonstrates hyper-dense (white) lesion, +/- oedema, +/- mass effect, +/- ventricular extension

Treatments

  • Secure airway – adjunct/intubation if low GCS
  • Oxygen
  • Blood pressure
    • Controversial (again)
    • RCP 2016 guidelines suggest:
    • if >150 systolic, reduce to 140
  • Anti-coagulation – stop all anti-coagulants and reversal of warfarin/heparin
  • Seizure prophylaxis if required
  • ICU/HASU
  • Consider intraventricular drain/clot evacuation