intracerebral haemorrhage (ICH) in adults

see also:

• stroke (CVA)
• subarachnoid haemorrhage (SAH)
• intraventricular haemorrhage (IVH) in adults

• ICH may be caused by penetrating and non-penetrating trauma to the head
• sites of non-traumatic ICH:
  • basal ganglia in 40-50%
  • lobar regions in 20-50% (mainly in those aged < 45 yrs in association with AVMs)
  • thalamus in 10-15%
  • pons in 5-12%
  • cerebellum in 5-10%
  • other brainstem sites in 1-5%
• aetiology of non-traumatic intracerebral bleeding in adults:
  • chronic hypertension causing development of Charcot-Bouchard aneurysms
  • hypertensive crisis
  • eclampsia
  • drug abuse such as sympathomimetics
  • autoregulatory dysfunction of cerebral blood flow (especially if thrombolytics used):
    • reperfusion injury
    • haemorrhagic transformation of ischaemic stroke
    • cold exposure
  • altered clotting system:
    • thrombolysis
    • anticoagulation
    • disseminated intravascular coagulation (DIC) including snakebite
    • bleeding diasthesis
  • arteriopathy such as cerebral amyloid angiopathy, vasculitis
  • haemorrhagic necrosis (neoplasm, infection)
  • cerebral venous thrombosis raising intracerebral vascular pressures

• acute onset headache
• vomiting
• decreased mental state
• +/- focal neurology
• approx. 1/3rd of cases with thalamic ganglionic bleeding extend into the ventricles causing intraventricular haemorrhage and potential for obstructive hydrocephalus
• it may cause a mass lesion effect with midline shift and potential for intracranial herniation

• most require Mx in a resuscitation room if deemed Mx is not futile
• iv access, bloods for FBE, U&E, clotting profile
• nurse at 30deg head up
• ABC's and consider early intubation if GCS is < 8
• CT brain to confirm bleed
• urgently reverse coagulopathy if possible
• liaise with neurosurgery

• overall, ICH has a > 40% 30 day mortality
• pontine and other brainstem ICH has a 75% 24 hour mortality