- Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more...
Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may occur within brain parenchyma or the surrounding meningeal spaces. Hemorrhage within the meninges or the associated potential spaces, including epidural hematoma, subdural hematoma, and subarachnoid hemorrhage, is covered in detail in other articles. Intracerebral hemorrhage (ICH) and extension of parenchymal bleeding into the ventricles (ie, intraventricular hemorrhage [IVH]) are detailed here.
Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.
Nontraumatic intracerebral hemorrhage most commonly results from hypertensive damage to blood vessel walls (eg, hypertension, eclampsia, drug abuse), but it also may be due to autoregulatory dysfunction with excessive cerebral blood flow (eg, reperfusion injury, hemorrhagic transformation, cold exposure), rupture of an aneurysm or arteriovenous malformation (AVM), arteriopathy (eg, cerebral amyloid angiopathy, moyamoya), altered hemostasis (eg, thrombolysis, anticoagulation, bleeding diathesis), hemorrhagic necrosis (eg, tumor, infection), or venous outflow obstruction (eg, cerebral venous thrombosis).
Nonpenetrating and penetrating cranial trauma are also common causes of intracerebral hemorrhage.Patients who experience blunt head trauma and subsequently receive warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage. According to one study, patients receiving clopidogrel have a significantly higher prevalence of immediate traumatic intracranial hemorrhage compared with patients receiving warfarin. Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving warfarin.
Chronic hypertension produces a small vessel vasculopathy characterized by lipohyalinosis, fibrinoid necrosis, and development of Charcot-Bouchard aneurysms, affecting penetrating arteries throughout the brain including lenticulostriates, thalamoperforators, paramedian branches of the basilar artery, superior cerebellar arteries, and anterior inferior cerebellar arteries.
Predilection sites for intracerebral hemorrhage include the basal ganglia (40-50%), lobar regions (20-50%), thalamus (10-15%), pons (5-12%), cerebellum (5-10%), and other brainstem sites (1-5%).
Intraventricular hemorrhage occurs in one third of intracerebral hemorrhage cases from extension of thalamic ganglionic bleeding into the ventricular space. Isolated intraventricular hemorrhage frequently arise from subependymal structures including the germinal matrix, AVMs, and cavernous angiomas.
Each year, intracerebral hemorrhage affects approximately 12-15 per 100,000 individuals, including 350 hypertensive hemorrhages per 100,000 elderly individuals. The overall incidence of intracerebral hemorrhage has declined since the 1950s.
Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the world.
Annually, more than 20,000 individuals in the United States die of intracerebral hemorrhage. Intracerebral hemorrhage has a 30-day mortality rate of 44%. Pontine or other brainstem intracerebral hemorrhage has a mortality rate of 75% at 24 hours. Hallevi et al reviewed the charts and CT scans of patients with intraventricular hemorrhage (IVH) to determine if the extension of the hemorrhage could be measured. Clinical outcome was determined by the modified Rankin Scale (mRS). IVH was also classified with an IVH score. The IVH score allowed rapid estimate of IVH volume by the practitioner and increased predictability for outcome.
Intracerebral hemorrhage has a higher incidence among populations with a higher frequency of hypertension, including African Americans. A higher incidence of intracerebral hemorrhage has been noted in Chinese, Japanese, and other Asian populations, possibly due to environmental factors (eg, a diet rich in fish oils) and/or genetic factors.
Intracerebral hemorrhage has a slight male predominance, though study results have been conflicting.
Cerebral amyloid angiopathy may be more common among women.
Phenylpropanolamine use has been associated with intracerebral hemorrhage in young women.
Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade until age 80 years. The relative risk of intracerebral hemorrhage is greater than 7 in individuals older than 70 years.
In individuals younger than 45 years, lobar hemorrhage is the most common site of and frequently is associated with AVMs.
Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in premature infants.
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun. 59(6):460-8.e1-7. [Medline]. [Full Text].
Hallevi H, Dar NS, Barreto AD, Morales MM, Martin-Schild S, Abraham AT, et al. The IVH score: a novel tool for estimating intraventricular hemorrhage volume: clinical and research implications. Crit Care Med. 2009 Mar. 37(3):969-74, e1. [Medline].
Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000 Dec 21. 343(25):1826-32. [Medline].
Vespa PM, O'Phelan K, Shah M, Mirabelli J, Starkman S, Kidwell C, et al. Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology. 2003 May 13. 60(9):1441-6. [Medline].
Woo D, Haverbusch M, Sekar P. Effect of untreated hypertension on hemorrhagic stroke. Stroke. 2004 Jul. 35(7):1703-8. [Medline].
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med. 2013 Feb. 20(2):140-5. [Medline]. [Full Text].
Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007 Apr. 38(4):1257-62. [Medline].
Bang OY, Buck BH, Saver JL, Alger JR, Yoon SR, Starkman S, et al. Prediction of hemorrhagic transformation after recanalization therapy using T2*-permeability magnetic resonance imaging. Ann Neurol. 2007 Aug. 62(2):170-6. [Medline].
Nishihara T, Nagata K, Tanaka S. Newly developed endoscopic instruments for the removal of intracerebral hematoma. Neurocrit Care. 2005. 2(1):67-74. [Medline].
Mayer SA, Brun NC, Begtrup K. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005 Feb 24. 352(8):777-85. [Medline].
Zaaroor M, Soustiel JF, Brenner B, Bar-Lavie Y, Martinowitz U, Levi L. Administration off label of recombinant factor-VIIa (rFVIIa) to patients with blunt or penetrating brain injury without coagulopathy. Acta Neurochir (Wien). 2008 Jul. 150(7):663-8. [Medline].
Honner SK, Singh A, Cheung PT, Alter HJ, Dutaret CG, Patel AK, et al. Emergency department control of blood pressure in intracerebral hemorrhage. J Emerg Med. 2011 Oct. 41(4):355-61. [Medline].
Bansal S, Blalock D, Kebede T, Dean NP, Carpenter JL. Levetiracetam versus (fos)phenytoin for seizure prophylaxis in pediatric patients with intracranial hemorrhage. J Neurosurg Pediatr. 2014 Feb. 13(2):209-15. [Medline].
Taylor S, Heinrichs RJ, Janzen JM, Ehtisham A. Levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage. Neurocrit Care. 2011 Aug. 15(1):80-4. [Medline].
Qureshi AI, Palesch YY, Martin R, Novitzke J, Cruz-Flores S, Ehtisham A. Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study. Arch Neurol. 2010 May. 67(5):570-6. [Medline].
Biffi A, Devan WJ, Anderson CD, et al. Statin use and outcome after intracerebral hemorrhage: Case-control study and meta-analysis. Neurology. 2011 May 3. 76(18):1581-8. [Medline].
Finelli PF, Kessimian N, Bernstein PW. Cerebral amyloid angiopathy manifesting as recurrent intracerebral hemorrhage. Arch Neurol. 1984 Mar. 41(3):330-3. [Medline].
Ritter MA, Droste DW, Hegedus K. Role of cerebral amyloid angiopathy in intracerebral hemorrhage in hypertensive patients. Neurology. 2005 Apr 12. 64(7):1233-7. [Medline].
Castellanos M, Leira R, Tejada J. Predictors of good outcome in medium to large spontaneous supratentorial intracerebral haemorrhages. J Neurol Neurosurg Psychiatry. 2005 May. 76(5):691-5. [Medline].
Alberts MJ, Latchaw RE, Selman WR. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005 Jul. 36(7):1597-616. [Medline].
Auer LM, Deinsberger W, Niederkorn K, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989 Apr. 70(4):530-5. [Medline].
Bang OY, Saver JL, Alger JR, Shah SH, Buck BH, Starkman S, et al. Patterns and Predictors of Blood-Brain Barrier Permeability Derangements in Acute Ischemic Stroke. Stroke. 2008 Nov 26. [Medline].
Bang OY, Saver JL, Liebeskind DS, Starkman S, Villablanca P, Salamon N, et al. Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis. Neurology. 2007 Mar 6. 68(10):737-42. [Medline].
Bradley WG Jr. MR appearance of hemorrhage in the brain. Radiology. 1993 Oct. 189(1):15-26. [Medline].
Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun. 38(6):2001-23. [Medline].
Broderick JP, Brott T, Tomsick T, et al. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg. 1993 Feb. 78(2):188-91. [Medline].
Broderick JP, Brott TG, Tomsick T, et al. Ultra-early evaluation of intracerebral hemorrhage. J Neurosurg. 1990 Feb. 72(2):195-9. [Medline].
Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007 Jan 27. 369(9558):293-8. [Medline].
Chiquete E, Ruiz-Sandoval MC, Alvarez-Palazuelos LE, Padilla-Martínez JJ, González-Cornejo S, Ruiz-Sandoval JL. Hypertensive intracerebral hemorrhage in the very elderly. Cerebrovasc Dis. 2007. 24(2-3):196-201. [Medline].
Connor MD, Modi G, Warlow CP. Accuracy of the Siriraj and Guy's Hospital Stroke Scores in urban South Africans. Stroke. 2007 Jan. 38(1):62-8. [Medline].
Demaerschalk BM, Aguilar MI. Treatment of acute intracerebral hemorrhage. Curr Treat Options Neurol. 2008 Nov. 10(6):455-67. [Medline].
Derex L, Nighoghossian N. Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update. J Neurol Neurosurg Psychiatry. 2008 Oct. 79(10):1093-9. [Medline].
Fiehler J, Remmele C, Kucinski T. Reperfusion after severe local perfusion deficit precedes hemorrhagic transformation: an MRI study in acute stroke patients. Cerebrovasc Dis. 2005. 19(2):117-24. [Medline].
Flemming KD, Wijdicks EF, St Louis EK, Li H. Predicting deterioration in patients with lobar haemorrhages. J Neurol Neurosurg Psychiatry. 1999 May. 66(5):600-5. [Medline].
Greenberg SM. Cerebral amyloid angiopathy: prospects for clinical diagnosis and treatment. Neurology. 1998 Sep. 51(3):690-4. [Medline].
Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials. Stroke. 1997 Nov. 28(11):2126-32. [Medline].
Hart RG, Boop BS, Anderson DC. Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke. 1995 Aug. 26(8):1471-7. [Medline].
Ivascu FA, Howells GA, Junn FS. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005 Nov. 59(5):1131-7; discussion 1137-9. [Medline].
Juvela S, Heiskanen O, Poranen A, et al. The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg. 1989 May. 70(5):755-8. [Medline].
Kang HS, Han MH, Kwon OK, Kwon BJ, Kim SH, Oh CW. Intracranial hemorrhage after carotid angioplasty: a pooled analysis. J Endovasc Ther. 2007 Feb. 14(1):77-85. [Medline].
Kassner A, Roberts T, Taylor K. Prediction of hemorrhage in acute ischemic stroke using permeability MR imaging. AJNR Am J Neuroradiol. 2005 Oct. 26(9):2213-7. [Medline].
Khatri P, Broderick JP, Khoury JC, Carrozzella JA, Tomsick TA. Microcatheter contrast injections during intra-arterial thrombolysis may increase intracranial hemorrhage risk. Stroke. 2008 Dec. 39(12):3283-7. [Medline].
Khatri P, Wechsler LR, Broderick JP. Intracranial hemorrhage associated with revascularization therapies. Stroke. 2007 Feb. 38(2):431-40. [Medline].
Kidwell CS, Chalela JA, Saver JL. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004 Oct 20. 292(15):1823-30. [Medline].
Klatsky AL, Friedman GD, Sidney S. Risk of hemorrhagic stroke in Asian American ethnic groups. Neuroepidemiology. 2005. 25(1):26-31. [Medline].
Lees KR, Zivin JA, Ashwood T. NXY-059 for acute ischemic stroke. N Engl J Med. 2006 Feb 9. 354(6):588-600. [Medline].
Leira R, Davalos A, Silva Y. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology. 2004 Aug 10. 63(3):461-7. [Medline].
Liu-DeRyke X, Rhoney D. Hemostatic therapy for the treatment of intracranial hemorrhage. Pharmacotherapy. 2008 Apr. 28(4):485-95. [Medline].
Lo WD, Lee J, Rusin J, Perkins E, Roach ES. Intracranial hemorrhage in children: an evolving spectrum. Arch Neurol. 2008 Dec. 65(12):1629-33. [Medline].
Lu A, Tang Y, Ran R. Brain genomics of intracerebral hemorrhage. J Cereb Blood Flow Metab. 2006 Feb. 26(2):230-52. [Medline].
Mascitelli L, Pezzetta F, Goldstein MR. Hemorrhagic stroke in the SPARCL study. Stroke. 2008 Nov. 39(11):e180; author reply e181. [Medline].
Mayer SA, Rincon F. Treatment of intracerebral haemorrhage. Lancet Neurol. 2005 Oct. 4(10):662-72. [Medline].
Mitchell P, Mitra D, Gregson BA, Mendelow AD. Prevention of intracerebral haemorrhage. Curr Drug Targets. 2007 Jul. 8(7):832-8. [Medline].
Narayan RK, Maas AI, Marshall LF, Servadei F, Skolnick BE, Tillinger MN. Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery. 2008 Apr. 62(4):776-86; discussion 786-8. [Medline].
Nghiemphu PL, Green RM, Pope WB, Lai A, Cloughesy TF. Safety of anticoagulation use and bevacizumab in patients with glioma. Neuro Oncol. 2008 Jun. 10(3):355-60. [Medline].
Nishijima DK, Dager WE, Schrot RJ, Holmes JF. The efficacy of factor VIIa in emergency department patients with warfarin use and traumatic intracranial hemorrhage. Acad Emerg Med. 2010 Mar. 17(3):244-51. [Medline].
Nyquist P. Management of acute intracranial and intraventricular hemorrhage. Crit Care Med. 2010 Mar. 38(3):946-53. [Medline].
Ogasawara K, Sakai N, Kuroiwa T, Hosoda K, Iihara K, Toyoda K, et al. Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg. 2007 Dec. 107(6):1130-6. [Medline].
Oppenheim C, Touze E, Hernalsteen D. Comparison of five MR sequences for the detection of acute intracranial hemorrhage. Cerebrovasc Dis. 2005. 20(5):388-94. [Medline].
Orakcioglu B, Becker K, Sakowitz OW, Unterberg A, Schellinger PD. Serial diffusion and perfusion MRI analysis of the perihemorrhagic zone in a rat ICH model. Acta Neurochir Suppl. 2008. 103:15-8. [Medline].
Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev. 2008 Oct 8. CD000200. [Medline].
Qureshi AI, Mohammad YM, Yahia AM. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med. 2005 Jan-Feb. 20(1):34-42. [Medline].
Qureshi AI, Suri MF. Acute reversal of clopidogrel-related platelet inhibition using methyl prednisolone in a patient with intracranial hemorrhage. AJNR Am J Neuroradiol. 2008 Nov. 29(10):e97. [Medline].
Rincon F, Mayer SA. Current treatment options for intracerebral hemorrhage. Curr Treat Options Cardiovasc Med. 2008 Jun. 10(3):229-40. [Medline].
Rincon F, Mayer SA. Intracerebral hemorrhage: getting ready for effective treatments. Curr Opin Neurol. 2010 Feb. 23(1):59-64. [Medline].
Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010 Jun 9. 303(22):2280-6. [Medline].
Sandercock P. Yes' or 'no' to routine statins after subarachnoid hemorrhage to prevent delayed cerebral ischaemia, vasospasm, and death? A cautionary tale of 2 meta-analyses. Stroke. 2010 Jan. 41(1):e1-2. [Medline].
Smith EE, Rosand J, Greenberg SM. Hemorrhagic stroke. Neuroimaging Clin N Am. 2005 May. 15(2):259-72, ix. [Medline].
Sorimachi T, Fujii Y, Morita K, Tanaka R. Predictors of hematoma enlargement in patients with intracerebral hemorrhage treated with rapid administration of antifibrinolytic agents and strict blood pressure control. J Neurosurg. 2007 Feb. 106(2):250-4. [Medline].
Steiner T, Rosand J, Diringer M. Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions. Stroke. 2006 Jan. 37(1):256-62. [Medline].
Struffert T, Doelken M, Adamek E, Schwarz M, Engelhorn T, Kloska S, et al. Flat-detector computed tomography with intravenous contrast material application in experimental aneurysms: comparison with multislice CT and conventional angiography. Acta Radiol. 2010 May. 51(4):431-7. [Medline].
Tuhrim S, Dambrosia JM, Price TR, et al. Prediction of intracerebral hemorrhage survival. Ann Neurol. 1988 Aug. 24(2):258-63. [Medline].
Vernooij MW, van der Lugt A, Ikram MA, Wielopolski PA, Niessen WJ, Hofman A, et al. Prevalence and risk factors of cerebral microbleeds: the Rotterdam Scan Study. Neurology. 2008 Apr 1. 70(14):1208-14. [Medline].
Viswanathan A, Chabriat H. Cerebral microhemorrhage. Stroke. 2006 Feb. 37(2):550-5. [Medline].
Zhu XL, Chan MS, Poon WS. Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke. 1997 Jul. 28(7):1406-9. [Medline].
|Hyperacute||< 24 hours||Oxyhemoglobin (intracellular)||Iso or hypo||Hyper|
|Acute||1-3 days||Deoxyhemoglobin (intracellular)||Iso or hypo||Hypo|
|Early subacute||>3 days||Methemoglobin||Hyper||Hypo|
|Late subacute||>7 days||Methemoglobin (extracellular)||Hyper||Hyper|
|Chronic||>14 days||Hemosiderin (extracellular)||Iso or hypo||Hypo|
|II||Intraventricular hemorrhage without ventriculomegaly|
|III||Intraventricular hemorrhage with ventriculomegaly|
|IV||Intraventricular hemorrhage with parenchymal hemorrhage|