Sections

Intracranial Hemorrhage

Sections Intracranial Hemorrhage
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
Tables
References

Follow-up

Further Outpatient Care

See the list below:

After hospital discharge, continued physical, occupational, and speech therapy may be required.
Administer medications to control hypertension and to prevent complications such as seizures, urinary tract infections, or venous thromboses.

Further Inpatient Care

Initial management of intracerebral hemorrhage generally is conducted in the ICU. Subsequent care generally includes the following:

Serial neurologic examinations
Treatment of elevated intracranial pressure
Placement of ventricular catheter should hydrocephalus develop
Avoidance of hypotension or hypertension (MAP = 70-130 mm Hg)
Use of isotonic solutions, such as normal saline, to minimize cerebral edema
Treatment with 3 X isotonic saline should hyponatremia due to cerebral salt wasting occur
Avoidance of hyperthermia
Treatment or prophylaxis of seizures
Treatment of urinary tract infections
Prevention of venous thrombosis with intermittent compression stockings plus or minus low-dose subcutaneous unfractionated or low molecular weight heparin
Prophylaxis for gastric ulcers
Physical, occupational, and speech therapy
Psychological support with cautious use of sedatives, if necessary
Repeat CT scan in case of clinical deterioration

Inpatient & Outpatient Medications

See the list below:

Antihypertensives for modification of blood pressure
Mannitol or other osmotic diuretics for elevated intracranial pressure
Acetaminophen for fever and headache relief
Fosphenytoin or other anticonvulsants for posttraumatic seizures
Famotidine or other antacids for gastric ulcer prophylaxis
Anticholinergics for bladder complications
Baclofen, diazepam, or tizanidine for spasticity
Amitriptyline, carbamazepine, or gabapentin for neuropathic pain

Transfer

Following prehospital and emergent stabilization, patients with intracerebral hemorrhage should be transferred to a medical facility with neurosurgical expertise.

Deterrence/Prevention

See the list below:

Early detection and aggressive treatment of hypertension
Cautious management of anticoagulation and other antithrombotic medications
Careful selection of subjects suitable for thrombolysis
Consideration of cerebral amyloid angiopathy as a significant risk factor for intracerebral hemorrhage^{[17, 18]}
Public education campaigns emphasizing the dangers of heavy alcohol intake and sympathomimetic use
Public education regarding traumatic brain injury, including appropriate use of safety equipment, precautions, and measures that may reduce the incidence of head injury
Prevention and management of preterm labor that may reduce intraventricular hemorrhage due to germinal matrix hemorrhage

Complications

See the list below:

Neurological deficits or death
Seizures
Hydrocephalus
Spasticity
Urinary complications
Aspiration pneumonia
Neuropathic pain
Deep venous thrombosis
Pulmonary emboli
Cerebral herniation

Prognosis

See the list below:

Early reduction in the level of consciousness carries an ominous prognosis.
The size and location of intracerebral hemorrhage provide useful prognostic information.
- Larger hematomas have a worse outcome.
- Lobar hemorrhage has a better outcome than deep hemorrhage.
- Significant volume of intraventricular blood is a poor prognostic indicator.
The presence of hydrocephalus is associated with a poor outcome.
Good outcome in medium to large intracerebral hemorrhage can be predicted on admission by neurologic severity, intracerebral hemorrhage location, and fibrinogen levels.^[19]

Patient Education

Educate patients regarding the following:

Treatment of hypertension
Warning signs and symptoms of stroke as well as preventive measures
Traumatic brain injury
Adverse effects of alcohol and sympathomimetic substances

Questions

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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Woo D, Haverbusch M, Sekar P. Effect of untreated hypertension on hemorrhagic stroke. Stroke. 2004 Jul. 35(7):1703-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Nishihara T, Nagata K, Tanaka S. Newly developed endoscopic instruments for the removal of intracerebral hematoma. Neurocrit Care. 2005. 2(1):67-74. [QxMD MEDLINE Link].
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Media Gallery

Intracranial hemorrhage. CT scan of right frontal intracerebral hemorrhage complicating thrombolysis of an ischemic stroke.
Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted, and gradient echo MRI illustration of intracerebral hemorrhage associated with a right frontal arteriovenous malformation.
Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted, and gradient echo MRI depiction of left temporal intracranial hemorrhage due to sickle cell disease.
This MRI reveals petechial intracerebral hemorrhage (ICH) due to cerebral venous thrombosis.
This CT scan and MRI revealed midbrain intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) associated with a cavernous angioma.
This MRI reveals hemorrhagic transformation of an ischemic infarct.

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Author

David S Liebeskind, MD, FAAN, FAHA, FANA Professor of Neurology and Director, Neurovascular Imaging Research Core, Director, Vascular Neurology Residency Program, Department of Neurology, University of California, Los Angeles, David Geffen School of Medicine; Director, UCLA Outpatient Stroke and Neurovascular Programs; Director, UCLA Cerebral Blood Flow Laboratory; Associate Neurology Director, UCLA Stroke Center

David S Liebeskind, MD, FAAN, FAHA, FANA is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Additional Contributors

Jeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University of California, Los Angeles, David Geffen School of Medicine

Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, National Stroke Association

Disclosure: Received the university of california regents receive funds for consulting services on clinical trial design provided to covidien, stryker, and lundbeck. from University of California for consulting.

Sections Intracranial Hemorrhage
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
Tables
References

Phase	Time	Hemoglobin	T1	T2
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

Grade	Hemorrhage Location
I	Subependymal hemorrhage
II	Intraventricular hemorrhage without ventriculomegaly
III	Intraventricular hemorrhage with ventriculomegaly
IV	Intraventricular hemorrhage with parenchymal hemorrhage

Intracranial Hemorrhage Follow-up

Further Outpatient Care

Further Inpatient Care

Inpatient & Outpatient Medications

Transfer

Deterrence/Prevention

Complications

Prognosis

Patient Education

References

Tables

Contributor Information and Disclosures

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