Introduction
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.
Large intracerebral hemorrhage with midline shift.
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
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)
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| References |
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Further Reading
Keywords
intracerebral hemorrhage, ICH, intracerebral bleeds, hypertension, neurologic function, cerebrovascular accident, CVA, stroke syndrome, thrombosis, embolism, hemorrhage, hemorrhagic stroke, cerebrovascular disease, neurologic complications, antithrombotic therapy, thrombolytic therapy, focal neurologic deficits, bleeding diatheses, iatrogenic anticoagulation, coagulopathies, anticoagulant therapy, iatrogenic hemorrhagic stroke, cerebral amyloidosis, cocaine abuse, mass effect of hematoma, hemiparesis, quadriparesis, hemisensory loss, aphasia, hemi-inattention, brainstem compression, brainstem herniation, apnea, limb ataxia, diplopia, nystagmus, oropharyngeal weakness, dysphagia, crossed signs, new-onset seizure, stroke, stroke management
