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  • Updated 04.21.2023
  • Released 07.16.1996
  • Expires For CME 04.21.2026

Hypertensive intracerebral hemorrhage



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

• An increase in hematoma size that is associated with poor outcome may be predicted by head CT.

• Smooth and sustained control of blood pressure may improve functional outcome.

• Anticoagulation-associated intracerebral hemorrhage has a high mortality rate. Coagulopathy should be reversed with agents specific for the anticoagulant present.

• Continuous hyperosmolar therapy; platelet transfusion, unless surgically indicated or severe thrombocytopenia; antiepileptic medications in the absence of seizures; or graduated knee-to-thigh compression stockings are not beneficial.

• Minimally invasive surgery for supratentorial hemorrhage may reduce mortality but not functional outcome.

• The indications for cerebellar hematoma evacuation include volume greater than 15 ml, neurologic deterioration, brainstem compression, and hydrocephalus.

• Mobilization should be considered after 24 hours from onset, but not before, as it is associated with increased 14-day mortality.

• Education of the home caregiver helps in coping with the challenges posed by intracerebral hemorrhage.

• Transferring patients to a specialized center with neurosurgical services is likely to improve their outcome, whether they undergo surgery or not. Telemedicine may aid in patient selection.

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

Historical note and terminology

Intracerebral hemorrhage is the bleeding into the brain parenchyma resulting from rupture of a cerebral artery. It accounts for approximately 10% of strokes (104; 113). Hypertension is the leading risk factor for intracerebral hemorrhage, although its role has decreased over the past decades (113; 45).

Intracerebral hemorrhage was first demonstrated at autopsy by Wepfer in 1658, long before blood pressure could be measured (40). The term spontaneous or primary intracerebral hemorrhage implies absence of a structural vulnerability. However, the most common causes of primary intracerebral hemorrhage are hypertension and amyloid angiopathy.

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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