Intracerebral Haemorrhage (ICH)

Definition

Intracerebral haemorrhage (ICH) is a type of stroke caused by bleeding within the brain tissue itself, leading to increased intracranial pressure and damage to brain cells. It is a medical emergency requiring prompt diagnosis and treatment to improve outcomes.

Aetiology

ICH can be caused by various factors, including:

• Hypertension (high blood pressure): The most common cause
• Cerebral amyloid angiopathy: Deposition of amyloid in the walls of blood vessels in the brain
• Anticoagulant or antiplatelet therapy
• Arteriovenous malformations (AVMs)
• Aneurysms
• Trauma to the head
• Brain tumours
• Coagulation disorders

Pathophysiology

ICH occurs when a blood vessel within the brain ruptures, leading to bleeding into the brain tissue. This bleeding causes a mass effect, increasing intracranial pressure and leading to direct damage to brain cells. The increased pressure can also reduce blood flow to other parts of the brain, causing further damage.

Risk Factors

• Hypertension
• Advanced age
• Use of anticoagulant or antiplatelet medications
• History of stroke or transient ischaemic attack (TIA)
• Smoking
• Alcohol abuse
• High cholesterol
• Diabetes
• Family history of stroke

Signs and Symptoms

• Sudden onset of severe headache
• Loss of consciousness or decreased level of consciousness
• Nausea and vomiting
• Weakness or paralysis, particularly on one side of the body
• Seizures
• Vision changes
• Difficulty speaking or understanding speech
• Confusion or disorientation
• Loss of balance or coordination

Investigations

• Clinical history and physical examination
• Non-contrast CT scan of the head: The first-line imaging to confirm ICH
• MRI of the brain: For further evaluation if needed
• Blood tests to assess coagulation status and underlying conditions
• Angiography if vascular malformation or aneurysm is suspected

Management

Primary Care Management

• Immediate referral to the hospital if ICH is suspected
• Initial supportive care, including airway management, breathing, and circulation (ABCs)
• Monitoring and management of blood pressure

Specialist Management

• Management in an intensive care unit (ICU) for close monitoring
• Control of intracranial pressure (e.g., mannitol, hypertonic saline)
• Surgical intervention if indicated (e.g., craniotomy to evacuate the haematoma)
• Reversal of anticoagulation if the patient is on blood thinners
• Management of underlying causes (e.g., hypertension, vascular malformations)
• Rehabilitation involving physical therapy, occupational therapy, and speech therapy
• Long-term follow-up to monitor for complications and secondary prevention

Example Management for Intracerebral Haemorrhage

A patient presenting with sudden onset of severe headache, weakness on one side of the body, and confusion should be referred to the hospital immediately. An urgent non-contrast CT scan should be performed to confirm the diagnosis of ICH. Initial management includes stabilisation of the patient’s airway, breathing, and circulation, and careful monitoring and control of blood pressure. If the patient is on anticoagulants, reversal agents should be administered. The patient should be managed in an ICU setting with neurosurgical consultation for possible surgical intervention. Post-acute care includes rehabilitation and long-term follow-up for secondary prevention of stroke.

References

1. NICE. (2024). Stroke and Transient Ischaemic Attack in Over 16s: Diagnosis and Initial Management. Retrieved from NICE
2. NHS. (2023). Intracerebral Haemorrhage. Retrieved from NHS
3. Broderick, J. P., et al. (2007). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. Stroke.
4. Feigin, V. L., et al. (2009). Worldwide Stroke Incidence and Early Case Fatality Reported in 56 Population-Based Studies: A Systematic Review. The Lancet Neurology.
5. Qureshi, A. I., et al. (2001). Spontaneous Intracerebral Hemorrhage. New England Journal of Medicine.