10B. Intracerebral haemorrhage (ICH)
Intracerebral haemorrhage (ICH) refers to haemorrhage into the brain parenchyme. It’s one form of haemorrhagic stroke.
We can distinguish two usual presentations of ICH. The typical presentation is in an elderly patient with hypertension, who has haemorrhage in deep brain structures, like basal ganglia, thalamus, pons, and/or cerebellum. This occurs due to rupture of microaneurysms in the brain which occur due to chronic hypertension. This is the most common presentation.
The other presentation is the atypical one, which occurs in younger or normotensive patients, who rather have haemorrhage in the cortical lobes. This occurs due to rupture of vascular malformations, coagulation disorders, or due to cerebral amyloid angiopathy.
The prognosis is poor, 50% of patients die within 30 days.
Etiology
- Typical ICH
- Hypertensive vasculopathy
- Anticoagulation
- Atypical ICH
- Vascular malformation (mostly in younger patients)
- Cerebral amyloid angiopathy (mostly in older patients)
- Anticoagulant therapy or coagulation disorders
- Trauma
Clinical features
As a form of stroke, ICH can’t be distinguished from ischaemic stroke clinically. However, certain features are more likely in ICH, including symptoms progressing gradually over minutes or hours, and symptoms like severe headache, vomiting, loss of consciousness, and severe hypertension.
Specific symptoms can occur depending on the location of the bleeding. If in the cerebellum, cerebellar symptoms can occur. If in the pons, tetraplaegia, pinpoint pupils, and brainstem symptoms can occur. Seizures occur almost exclusively in ICH which affects the cortical lobes.
Diagnosis and evaluation
As a form of stroke, native CT should be performed ASAP. The haemorrhage is visible as a hyperdense lesion in the brain parenchyma.
If the presentation is atypical, i.e. the patient is young or normotensive, or the CT shows lobar ICH, then the underlying etiology must be determined by further examinations. CT or MR angiography or DSA can show vascular malformations, and if negative we should screen for a bleeding disorder. Cerebral amyloid angiopathy usually causes multiple small haemorrhages.
Treatment
Treatment is mainly supportive. It’s important to stabilize the patient, decrease blood pressure to 140/90, and reverse anticoagulation if present.
Surgical evacuation of the haematoma can be performed if there is brain herniation or large cerebellar haematoma.
If there is blood in the ventricles, we may drain it or apply thrombolytics intraventricularly to prevent hydrocephalus.