Diagnosis

Intracerebral hemorrhage

Etiology

Cause [rus][kyi]

• Traumatic

• Spontaneous non-traumatic:

  • Primary: >85% of hemorrhagic strokes

    • Hypertension

    • Cerebral amyloid angiopathy

  • Secondary:

    • Atherosclerosis

    • Aneurysm

    • AV-malformation

    • Blood disorders like hemophilia/sickle cell anemia

    • Liver failure

    • Brain tumor

    • Infection

    • Eclampsia

    • Drug abuse: cocaine

    • Cerebral venous sinus thrombosis

    • Reperfusion injury (hemorrhagic transformation)

Pathophysiology [kyi]

1. The initial extravasation of blood into the parenchyma

2. Subsequent bleeding around the clot causing expansion

3. Swelling or edema around the hematoma

4. Sudden increase in intracranial pressure

5. Compression and disruption of the surrounding neuronal tissue

6. Focal neurological deficit, decreased level of consciousness

7. May cause herniation --> lower cerebral perfusion pressures --> secondary brain injury

Risk factors [o5w]

• Hypertension

• Diabetes

• Hearth disease

• Atrial fibrillation

• Smoking

• Alcohol

• Anticoagulant drugs

• Antiplatelet drugs

• Dyslipidemia

• Pre-TIA

Complications [kyi]

• Intraventricular hemorrhage

• Obstructive hydrocephalus

• Seizures

• Deep vein thrombosis

• Pulmonary embolism

Epidemiology

Incidence per 100.000 [ago][dks][w39][o5w][wtk]

Approach

• Blood test: Platelets, PT-INR, aPTT, infection-tests, electrolytes, osmolarity, toxicology screen (alcohol)

• Ophtalmoscopy

• CT caput

• MR caput

• Lumbar puncture

• ECG

• Biopsy

Treatment

1. Airway: endotracheal intubation for airway protection if decreased consciousness [rus]

2. If increased intracranial pressure:

   • Hyperventilate

   • Mannitol

3. Antihypertensive agents to lower blood pressure (mean arterial pressure < 130 mm Hg): Labetalol, Nicardipine, Mannitol, Acetaminophen

4. Maintain euvolemia

5. Avoid hyperthermia

6. Correct coagulopathy: fresh frozen plasma, vitamin K, protamine, platelet transfusions

7. Anticonvulsant if seizure: phenytoin, levetiracetam

8. Profylaxis: Antacids, statins

9. Nonsurgical management:

   • Minimal neurological deficits

   • Intracerebral hemorrhage volumes less than 10 mL

   • Bedrest during the first 24 hours

10. Surgery:

    • Indication:

      • Cerebellar hemorrhage greater than 3 cm

      • Intracerebral hemorrhage associated with a structural vascular lesion

      • Young patients with lobar hemorrhage

    • Approach:

      • Craniotomy and clot evacuation

      • Stereotactic aspiration with thrombolytic agents

      • Endoscopic evacuation

Differential diagnoses

Arteriovenous malformation, Brain tumor, Cerebral aneurysm, Cerebral venous sinus thrombosis, Encephalitis, Endocarditis, Epidural hematoma, Epilepsy, Hydrocephalus, Meningitis, Multiple sclerosis, Stroke, Subarachnoid hemorrhage, Subdural hematoma, Syndrome of inappropriate antidiuretic hormone secretion, Toxoplasmosis