Intracerebral Haemorrhage

Bleeding into brain parenchyma, usually from a primary vascular cause.

This discusses “pure” ICH, which most commonly occurs with haemorrhagic stroke.

Pure ICH from aneurysmal bleeding is rare, as the majority have subarachnoid (SAH) or ventricular (IVH) extension. Trauma often causes a variety of intra- and extra-axial bleeds, although isolated contusions are common.

Epidemiology and Risk Factors

Pathophysiology

Haemorrhage:

  • Size is a function of the anatomical resistance of the site of bleeding
    • Cortical typically larger than pontine
  • Degree of dysfunction is determined by the region of brain destroyed
    • Pontine typically more disabling than cerebral

Intracranial haemorrhage can be divided into:

  • Intra-axial
    Intracerebral haemorrhage.
  • Extra-axial
    • EDH
    • SDH
    • SAH
    • IVH

Aetiology

Causes:

  • Vascular
    • Hypertensive haemorrhage
      Prolonged systemic hypertension results in vascular degeneration and formation of microaneurysms, usually at bifurcations.
    • Aneurysmal
      Cerebral aneurysms can occasionally cause ICH without SAH.
    • AVM
    • Microvascular
      • Arteriolesclerosis
      • Cerebral Amyloid Angiopathy
  • Trauma

Clinical Manifestations

  • Usually no prodrome
  • Sudden onset and rapid deterioration with:
    • Focal neurology
    • Depression of consciousness
    • ↑ ICP
      Ocular palsies.

Diagnostic Approach and DDx

Key differential diagnoses:

  • Ischaemic stroke
    Difficult to distinguish clinically in early stages.

Investigations

Bedside:

Laboratory:

Imaging:

Other:

Management

  • Limit haematoma expansion
  • Reverse anticoagulation
  • Control ICP

Resuscitation:

Principles of management are the same as for ischaemic stroke (covered under Stroke), with key differences being:

  • More aggressive blood pressure control
  • Avoid anticoagulation and thrombolysis
  • C
    • Hypertension control
      Acute ↓ of SBP to 130-150mmHg, ideally within 1 hour.
  • D
    • ICP control
    • ICP monitoring
      For GCS ⩽8.

Specific therapy:

Reversal of therapeutic anticoagulation is covered in detail under ?sec-anticoag.

  • Pharmacological
    • Reversal of anticoagulation
      • Warfarin
        PCC, irrespective of INR. Can be given prior to INR result returning.
      • Direct Xa inhibitor
        • Consider Andexenat alfa
        • PCC may be used to improve haemostasis
  • Procedural
    • EVD
      Indicated in:
      • Secondary hydrocephalus
      • Intraventricular extension
  • Physical

Supportive care:

  • H
    • Platelets
      Only for correction of thrombocytopenia or prior to neurosurgical intervention.

Disposition:

Marginal and Ineffective Therapies

  • Hyperventilation
    ↓ PaCO2 to <30mmHg results in ↓ CBF and cerebral ischaemia
  • Steroids

Anaesthetic Considerations

Complications

Prognosis

Key Studies

  • PATCH (2016)
    • 190 European adults on antiplatelet therapy with supratentorial non-traumatic, non-aneurysmal ICH and a GCS from 8-15, without intraventicular haemorrhage, history of coagulopathy
    • Multicentre (41), assessor blinded RCT
    • 91% power to detect OR of 0.43 (!) between pairs of mRS categories
    • Platelets vs. standard care
      • Platelets
        • 5 units if on COX inhibitor
        • 10 units if on ADP receptor inhibitor
        • 4 did not receive platelets
      • Control
        • 2 received platelets
    • Worse functional outcome at 3 months (OR ~2, CI 1.2-3.6)

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.
  2. Baharoglu MI, Cordonnier C, Salman RAS, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. The Lancet. 2016;387(10038):2605-2613. doi:10.1016/S0140-6736(16)30392-0