Contents

Search

intracerebral hemorrhage (ICH)

hemorrhage directly into the cerebral parenchyma see intraparenchymal hemorrhagic stroke for - cerebellar hemorrhage - pontine hemorrhage Etiology: 1) hypertension (most common) - putamen, thalamus, basal ganglia [12] 2) amyloid angiopathy (common in elderly) - suspect in patient with hemorrhage outside distribution common for hypertensive hemorrhage (supratentorial lobar hemorrhages) [12] 3) arteriovenous malformations (AVM) 4) bleeding diatheses 5) pharmacologic anticoagulation 6) antiplatelet agents - combination of NSAIDs & antidepressants (NNH=244) [8] - low dose aspirin 75-300 mg QD does not increase risk [10] 7) CNS infections 8) brain tumor with hemorrhage 9) cocaine may be precipitating factor 10) tobacco abuse, alcohol abuse 11) decreased LDL cholesterol increases risk [2] 12) increased HDL cholesterol increases risk [2] 13) SSRI use [2] Epidemiology: - intraparenchymal hemorrhagic strokes account for 15% of all strokes Pathology: - most commonly small penetrating vessels in the putamen, thalamus bleed into the brain parenchyma - basal ganglia, pons, cerebellum also affected - hypertension is a risk factor for hematoma expansion [2] - blood pressure > 140/80 mm Hg after intracerebral hemorrhage is associated with poor prognosis [2] Clinical manifestations: 1) 1/3 of non-comatose patients deteriorate rapidly - 50% mortality 3) hematomas > 50 mL are most likely to cause deterioration 4) patients with amyloid-related hemorrhages a) frequently normotensive b) generally have prior cognitive deficits Laboratory: urine toxicology for cocaine Special laboratory: - cerebral angiography with catheter intra-arterial digital subtraction a) patients < 45 years of age b) intraparenchymal hemorrhage related to cocaine (high incidence of vascular anomalies) c) spontaneous intraventricular hemorrhage without parenchymal hemorrhage [14] - continuous EEG monitoring - probably indicated for patients with mental status changes disproportional to the extent of brain injury [7] Radiology: - non-contrast computed tomography (CT) of the brain - repeat neuroimaging may be required if changes in neurological status occur due to - expansion of hematoma - cerebral edema - computed tomography angiography (CTA) - venography [14] - exclude central venous thrombosis - lobar spontaneous intracranial hemorrhage (ICH) in patients < 70 years - deep/posterior fossa hemorrhage in patients < 45 years or < 70 years without hypertension - magnetic resonance angiography - spontaneous ICH & negative CTA/venography [14] Complications: - much higher mortality than ischemic stroke [2] - 15-40% 90 day mortality [14] Differential diagnosis: - ischemic stroke can not be distinguished from intracranial hemorrhage on the basis of clinical manifestations - head CT without contrast distinguishes Management: 1) see general measures under stroke (CVA) 2) neurosurgery consultation a) craniotomy for arteriovenous malformation (AVM) b) benefits of surgery uncertain for supratentorial ICH [7] c) also see intracranial hemorrhage 3) treatment of systolic hypertension > 180 mm Hg [2] - avoid IV nitroprusside & nitroglycerin [2] - nitroprusside & nitroglycerin may raise intracranial pressure [2] - nicardipine or labetolol to maintain systolic blood pressure between 140-160 mm Hg [2,5]; target systolic BP is 140 mm Hg [2] - assumption is that excessively high systolic blood pressure will increase hematoma size - lowering of systolic BP to 140 mm Hg may not be harmful [4]; may be helpful (no lower limit cited) [7]; may be harmful [2] - target systolic blood pressure of 110-139 mm Hg does not improve outcomes relative to standard treatment of 140-179 mm Hg [9] - maintain systolic BP 130-150 mm Hg, target systolic BP 140 mm Hg [14] - avoid goals of systolic BP < 140 mm Hg [2] 4) mannitol, hypertonic saline, barbiturate coma, hyperventilation to reduce intracranial pressure 5) do not use glucocorticoids to lower intracranial hypertension [7] 6) correct elevated INR - vitamin K IV for warfarin-associated intracranial hemorrhage - add 4-factor prothrombin complex concentrate [2] - for patients taking direct oral factor Xa inhibitor (rivaroxaban, apixaban) stop the anticoagulant & treat with 4-factor prothrombin complex concentrate or andexanet alfa - for dabigatran reverse anticoagulation with idarucizumab - 4-factor prothrombin complex concentrate may have fewer complications & correct the INR more rapidly than fresh frozen plasma [7] - 4-factor prothrombin complex preferable to fresh frozen plasma [14] - recombinant factor VIIa of no benefit [6] 7) routine platelet transfusion not indicated [2] 8) statin use is controversial [3] (not addressed in [7]) 9) prophylaxis for venous thromboembolism in non-ambulatory patients - pneumatic compression from hospital day 1 [7] - low dose LMW heparin [14] 10) postpone do not resuscitate order until at least the 2nd day of hospitalization [7] 11) for patients with spontaneous ICH, inpatient stroke unit indicated [14] 12) followup - neurorehabilitation - long-term goal of BP <130/80 is reasonable for prevention of recurrent ICH [7] - avoid anticoagulants for 4 weeks - with or without mechanical heart valve - may decrease recurrence of ICH [7] - pharmacologic prophylaxis for venous thromboembolism safe after 24 hours if no evidence of expanding hematoma [2] - safe to restart antiplatelet agent after 11 weeks [11,13]

General

hemorrhagic stroke

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1019-20
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Westover MB et al Statin Use Following Intracerebral Hemorrhage: A decision analysis. Archives of Neurology Jan 10, 2011 PMID: 21220650 http://archneur.ama-assn.org/cgi/content/full/archneurol.2010.356 - Goldstein LB Statins After Intracerebral Hemorrhage: To Treat or Not to Treat Archives of Neurology Jan 11, 2011 PMID: 21220651 http://archneur.ama-assn.org/cgi/content/full/archneurol.2010.349 - Goldstein LB. Letter by goldstein regarding article, "statins and intracerebral hemorrhage" Circulation. 2012 Jun 12;125(23):e1015 PMID: 22689936 - Goldstein LB Hemorrhagic stroke in the stroke prevention by aggressive reduction in cholesterol levels study. Neurology. 2009;72:1447-1448 PMID: 19380708 - Goldstein LB Statin Therapy Should be Discontinued in Patients with Hemorrhagic Stroke. Stroke 2013; 44: 2058-2059 PMID: 2376594 http://stroke.ahajournals.org/content/44/7/2058.extract# - Goldstein LB, Amarenco P, Szarek M et al Hemorrhagic stroke in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels study. Neurology. 2008 Jun 10;70(24 Pt 2):2364-70 PMID: 18077795 - Hackam DG, Woodward M, Newby LK et al Statins and intracerebral hemorrhage. Circulation. 2011;124:2233-2242 PMID: 22007076 - Flint AC, Conell C, Rao VA Effect of statin use during hospitalization for intracerebral hemorrhage on mortality and discharge disposition. JAMA Neurol. 2014 Nov;71(11):1364-71 PMID: 25244578 - McKinney JS, Kostis WJ. Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke. 2012 Aug;43(8):2149-56 PMID: 22588266 - Leker RR, Khoury ST, Rafaeli G et al Prior Use of Statins Improves Outcome in Patients With Intracerebral Hemorrhage. Prospective Data from the National Acute Stroke Israeli Surveys (NASIS). Stroke. 2009; 40: 2581-2584 PMID: 19407227 - Westover MB, Bianchi MT, Eckman MH, Greenberg SM. Statin use following intracerebral hemorrhage: a decision analysis. Arch Neurol. 2011 May;68(5):573-9. PMID: 21220650 - Gandey A Statins Not Recommended for Patients With Intracerebral Hemorrhage. Medscape Multispecialty. January 11, 2011 http://www.medscape.com/viewarticle/735596 - Athyros VG1, Tziomalos K, Karagiannis A et al Aggressive statin treatment, very low serum cholesterol levels and haemorrhagic stroke: is there an association? Curr Opin Cardiol. 2010 Jul;25(4):406-10 PMID: 20375883 - Gaist D, Garcia Rodriguez LA, Hallas J et al Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage. Neurology. 2023 Aug 30:10.1212/WNL.0000000000207792 PMID: 37648526 https://n.neurology.org/content/early/2023/08/30/WNL.0000000000207792
  4. Anderson CS et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013 May 29 PMID: 23713578
  5. Morgenstern LB, Hemphill JC 3rd, Anderson C et al Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep;41(9):2108-29 PMID: 20651276
  6. The NNT: Recombinant Activated Factor VII for Acute Spontaneous Intracerebral Hemorrhage. http://www.thennt.com/nnt/factor-vii-for-intracerebral-hemorrhage/ - Al-Shahi Salman R Haemostatic drug therapies for acute spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005951 PMID: 19821350 - Diringer MN, Skolnick BE, Mayer SA et al Thromboembolic events with recombinant activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Stroke. 2010 Jan;41(1):48-53. PMID: 19959538
  7. Hemphill JC 3rd, Greenberg SM, Anderson CS et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015 May 28 PMID: 26022637
  8. Shin JY, Park MJ, Lee SH et al Risk of intracranial haemorrhage in antidepressant users with concurrent use of non-steroidal anti-inflammatory drugs: nationwide propensity score matched study. BMJ 2015;351:h3517 PMID: 26173947 http://www.bmj.com/content/351/bmj.h3517 - Mercer SW et al Risk of intracranial haemorrhage linked to co-treatment with antidepressants and NSAIDs. BMJ 2015;351:h3745 PMID: 26173949 http://www.bmj.com/content/351/bmj.h3745
  9. Qureshi AI et al Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. June 8, 2016 PMID: 27276234 http://www.nejm.org/doi/full/10.1056/NEJMoa1603460
  10. Cea Soriano L et al. Low-dose aspirin and risk of intracranial bleeds: An observational study in UK general practice. Neurology 2017 Nov 28; 89:2280 PMID: 29093065 http://n.neurology.org/content/89/22/2280
  11. RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial. Lancet. May 22, 2019 PMID: 31128924 Free Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30840-2/fulltext
  12. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  13. Al-Shahi Salman R, Dennis MS, Sandercock PAG et al Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage. Extended Follow-up of the RESTART Randomized Clinical Trial. JAMA Neurol. 2021. September 3, 2021 PMID: 3447782 https://jamanetwork.com/journals/jamaneurology/fullarticle/2783812
  14. Greenberg SM et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke 2022 May 17; [e-pub] PMID: 35579034 Review https://www.ahajournals.org/doi/10.1161/STR.0000000000000407