Intracerebral hemorrhage
Spontaneous bleeding into brain parenchyma, most often from chronic hypertension affecting deep penetrating vessels or from cerebral amyloid angiopathy in lobar locations, diagnosed by noncontrast CT and managed with acute blood pressure lowering, reversal of anticoagulation, and surgical evacuation for select cerebellar or deteriorating hemorrhages.
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What this article covers
- Overview
Definition: intracerebral hemorrhage (ICH) is spontaneous bleeding into the brain parenchyma from a ruptured small vessel, distinct from bleeding confined to the subarachnoid space or the ventricular…
- Epidemiology
Proportion of stroke: ICH accounts for 10% to 30% of all nonischemic strokes.
- Risk factors
Chronic hypertension: the dominant risk factor for deep (basal ganglia, thalamus, pons, cerebellum) ICH, from lipohyalinosis and microaneurysm formation in penetrating arterioles.
- Pathophysiology
Hypertensive vessel injury: sustained hypertension causes lipohyalinosis and microaneurysm formation in small penetrating arteries; rupture produces a hematoma in the basal ganglia, thalamus, pons, or cerebellum.
- Clinical features
Abrupt focal neurologic deficit: contralateral weakness, sensory loss, or aphasia depending on hematoma location, evolving over minutes.
- Differential diagnosis
Acute ischemic stroke: similar abrupt focal deficit but without the prominent early headache and depressed consciousness of ICH; distinguished by the absence of blood on noncontrast CT.
- Diagnosis
Noncontrast head CT establishes the diagnosis: CT identifies acute blood as hyperdensity within minutes of symptom onset and reliably distinguishes ICH from ischemic stroke, which is often not yet visible on CT.
- Management
First, control blood pressure: for a presenting systolic blood pressure of 150 to 220 mmHg, treat acutely to a target systolic of 140 mmHg; avoid nitroprusside and nitroglycerin, which can raise intracranial pressure.
- Complications
Hematoma expansion: the leading cause of early deterioration, tied to uncontrolled blood pressure and ongoing coagulopathy.
- Prognosis
ICH score predicts 30-day mortality: rising with each point from GCS, hematoma volume 30 cm3 or greater, intraventricular hemorrhage, infratentorial origin, and age 80 or older.
- Prevention
Blood pressure control is the mainstay of prevention: sustained control of chronic hypertension reduces both first and recurrent hypertensive ICH.
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Related articles
- Ischemic stroke
Ischemic stroke is sudden focal neurologic deficit from arterial occlusion confirmed by infarction on neuroimaging. Diagnosis relies on urgent noncontrast head CT to exclude hemorrhage; treatment is IV alteplase within 4.5 hours and mechanical thrombectomy for large-vessel occlusion within an extended window, followed by antiplatelet therapy and risk-factor control.
- Lacunar stroke
Small subcortical infarct, under 1.5 cm, from occlusion of a single penetrating artery, most often caused by hypertensive lipohyalinosis, producing one of five classic pure motor, pure sensory, ataxic hemiparesis, dysarthria-clumsy hand, or mixed sensorimotor syndromes without cortical signs, diagnosed by MRI and managed with the standard acute stroke pathway plus aggressive antiplatelet, statin, and blood pressure secondary prevention.
- Increased intracranial pressure
Sustained intracranial pressure above 20-22 mmHg from mass effect, edema, hydrocephalus, or venous outflow obstruction, diagnosed by clinical signs plus invasive monitoring and treated stepwise with head elevation, hyperosmolar therapy (mannitol or hypertonic saline), CSF diversion, and decompressive surgery when refractory.
- Subarachnoid hemorrhage
Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space, most often from a ruptured saccular (berry) aneurysm, presenting as the worst headache of a patient's life. Diagnosis is noncontrast head CT, then lumbar puncture if CT is negative, then catheter angiography to define the aneurysm; management is early aneurysm securement, blood pressure control, and nimodipine to reduce delayed cerebral ischemia from vasospasm.