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  • Updated 12.28.2023
  • Released 12.18.2001
  • Expires For CME 12.28.2026

Nontraumatic intracerebral hemorrhage



Intracerebral hemorrhage is much less common than ischemic stroke but is associated with a significantly high mortality and morbidity. Intracerebral hemorrhage frequently affects the basal ganglia, thalamus, cerebral lobes, pons, and cerebellum. Hypertension, cerebral amyloid angiopathy, and anticoagulation are major causes of intracerebral hemorrhage. The cerebellum has emerged as a frequent location of coagulant-associated intracranial hemorrhage. Statins are associated with only a marginal risk of intracerebral hemorrhage. Non-vitamin K antagonist oral anticoagulants are associated with lesser frequency of intracerebral hemorrhage to that of smaller size. Alcohol consumption in moderate amounts decreases the risk of both lobar and nonlobar intracerebral hemorrhage. Carriers of apolipoprotein E2 and E4 have an increased risk of intracerebral hemorrhage in lobar locations, presumably because of the effects of these gene variants on risk of cerebral amyloid angiopathy. Genetic studies identify 1q22 as a susceptibility locus for intracerebral hemorrhage. A “Causal Classification System for Intracerebral Hemorrhage” divides intracerebral hemorrhages in five subtypes. These include arteriolosclerosis, cerebral amyloid angiopathy, mixed small vessel disease, other rare forms of small vessel disease (genetic), and secondary causes (macrovascular, tumor, and other rare causes). Hematoma expansion is an accurate predictor of poor outcome of intracerebral hemorrhage. "Spot sign" on CT angiography has been reported to predict hematoma expansion. Strict blood pressure control may prevent further enlargement of hematoma. Anticoagulation-related intracerebral hemorrhage is often fatal, and rapid reversal of anticoagulation is the most effective therapy currently available. Severe COVID-19 is often associated with marked coagulopathy predisposing an intracerebral hemorrhage. Intracerebral hemorrhage can be a devastating complication of COVID-19. Vaccine-induced immune thrombocytopenia and thrombosis is characterized by immune-mediated thrombocytopenia and cerebral venous thrombosis and cerebral hemorrhage following the ChAdOx1 nCoV-19 adenoviral vector vaccine administration. It is associated with high mortality. Levetiracetam is a preferred drug for seizure control as it has a neuroprotective effect against posthemorrhagic stroke brain injury. Surgical evacuation of hematoma for supratentorial intracerebral hemorrhage was not shown to be beneficial. Considering a high rate of early neurologic deterioration in the first few hours, the American Heart Association recommends identifying patients at high risk of hematoma expansion. The FAST-MAG trial suggested that magnesium sulfate might reduce hematoma growth and neurologic decline in stroke patients, but further research is necessary to confirm these preliminary findings. In this article, the author reviews the different aspects of intracerebral hemorrhage in detail.

Key points

• Intracerebral hemorrhage is a common cause of stroke.

• It results from hypertensive damage to blood vessels, rupture of an aneurysm or arteriovenous malformations, cerebral amyloid angiopathy, altered hemostasis (like thrombolysis and anticoagulation), hemorrhagic necrosis (like tumor and infection), or substance abuse (cocaine).

• Common sites for involvement include the basal ganglia, lobes of cerebral hemispheres, thalamus, pons, cerebellum, and other brainstem sites.

• Computed tomography readily demonstrates acute hemorrhage.

• Initial management is focused on maintaining breathing, circulation, and fluid and electrolyte balance.

• Quick hemostasis to prevent hematoma expansion, surgical removal of clots, removal of intraventricular blood, and prompt blood pressure control improve outcomes.

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