Hypertensive intracerebral hemorrhage

Adrian Marchidann MD (Dr. Marchidann of SUNY Health Science Center has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released July 16, 1996; last updated November 22, 2016; expires November 22, 2019

Overview

The author provides an update on the progress in imaging modalities utilized in patients with intracerebral hemorrhage. New prognosis scores are introduced and the impact of an early do-not-resuscitate order is discussed. In addition, the latest clinical trials on blood and intracranial pressure management are reviewed.

Key points

 

• The principles of elevated intracranial pressure management are borrowed from the traumatic brain injury literature.

 

• Invasive monitoring of intracranial pressure was found beneficial in some studies but not in the only controlled study of patients with traumatic brain injury.

 

• Surgical decompression does not improve the outcome in patients with elevated intracranial pressure.

 

• Rapid blood pressure control is safe. It is still unclear what is the optimal blood pressure and how fast it should be reached.

 

• There are several surgical modalities to reduce the volume of hematoma and surrounding edema with or without the aid of tPA, many of which are still in the experimental stage only.

 

• Early surgery may improve the outcome of patients with Glasgow Coma Scale 9 to 12, hematoma volume of 20 to 50 ml, and perhaps those with superficial hematomas without intraventricular blood.

 

• Although patients presenting in coma rarely survive after surgical treatment, there is not enough information to recommend selection criteria for surgery.

 

• Transfer of patients to a specialized center with neurosurgical services is likely to improve their outcome, whether or not they have surgery.

Historical note and terminology

Intracerebral hemorrhage (ICH) is the bleeding into the brain parenchyma resulting from rupture of a cerebral artery. It accounts for approximately 10% of strokes (Matsumoto et al 1973; Mohr et al 1978). Hypertension (HTN) is the leading risk factor for intracerebral hemorrhage and is estimated to occur in 72% to 81% of patients (Mohr et al 1978; Furlan et al 1979).

Intracerebral hemorrhage was first demonstrated at autopsy by Wepfer in 1658, long before blood pressure could be measured (Fields and Lemak 1989). The association between miliary aneurysms of intracerebral arteries and parenchymal hemorrhage described by Charcot (Charcot and Bouchard 1868) was later supported by other investigators (Russell 1963; Cole and Yates 1967; Fisher 1971). Fisher proposed that hypertensive intracerebral hemorrhage results from rupture of lipohyalinotic arteries in the deep regions of the brain (Fisher 1971).

The introduction of CT in 1973 has revolutionized the diagnosis of intracerebral hemorrhage. CT reliably diagnoses bleeding and differentiates hemorrhagic from ischemic stroke. MRI of the brain provides additional information, including more precise evolution of the hemorrhage, and it provides clues regarding the etiology. CT angiography plays an increasing role in diagnosis of secondary intracerebral hemorrhage and is as effective as digital subtraction angiography at detecting most vascular malformations.

Surgical treatment of hypertensive intracerebral hemorrhage was first reported by Cushing (Cushing 1903). In spite of the advances in surgical techniques such as CT-guided stereotactic aspiration and clot dissolving, surgical evacuation of the clot, with few exceptions, is still in the experimental phase.

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.