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  • Updated 02.15.2022
  • Released 07.16.1996
  • Expires For CME 02.15.2025

Hypertensive intracerebral hemorrhage

Introduction

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 pressure and intracranial pressure management are reviewed.

Key points

• The Charcot-Bouchard aneurysms, historically implicated in the etiology of intracerebral hemorrhage, may not cause hemorrhage but may reflect severe cerebral vascular disease.

• Rapid blood pressure control does not improve the outcome, and if excessive, may lead to ischemic stroke. It is still unclear what the optimal blood pressure is and how fast it should be reached.

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

• Invasive monitoring of intracranial pressure is of unknown benefit.

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

• Minimally invasive surgery has shown promising results that need to be validated in randomized controlled studies.

• Although patients presenting in coma may 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 undergo surgery. Telemedicine may aid in patient selection.

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 (103; 112). Hypertension is the leading risk factor for intracerebral hemorrhage, although its role has decreased over the past decades (112; 45).

Intracerebral hemorrhage was first demonstrated at autopsy by Wepfer in 1658, long before blood pressure could be measured (40). The association between miliary aneurysms of intracerebral arteries and parenchymal hemorrhage described by Charcot (23) was later supported by other investigators (148; 28; 42). Fisher proposed that hypertensive intracerebral hemorrhage results from rupture of lipohyalinotic arteries in the deep regions of the brain (42).

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 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 (29). Despite 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.

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