Intracerebral Haemorrhage

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Intracerebral haemorrhage (ICH) is a type of stroke caused by bleeding directly into the brain parenchyma, leading to increased intracranial pressure and neurological dysfunction.

Aetiology

ICH is caused by rupture of small penetrating arteries due to various underlying conditions.

Common Causes:

  • Hypertension (most common): chronic high blood pressure weakens vessel walls.
  • Cerebral amyloid angiopathy (CAA): common in the elderly, related to amyloid deposition in vessel walls.
  • Coagulopathy: use of anticoagulants (e.g., warfarin, DOACs), thrombocytopenia.
  • Aneurysm or arteriovenous malformation (AVM): congenital vascular abnormalities.
  • Head trauma: direct injury causing haemorrhage.
  • Drug use: cocaine or amphetamines causing sudden hypertension.

Pathophysiology

  • Bleeding occurs due to vessel rupture, leading to haematoma formation.
  • Haematoma expansion increases intracranial pressure (ICP), causing secondary brain injury.
  • Oedema and inflammation around the haematoma worsen neurological impairment.
  • Compression of vital brain structures can lead to herniation and death.

Risk factors

  • Hypertension (strongest risk factor).
  • Advanced age.
  • Excessive alcohol consumption.
  • Smoking.
  • Previous ischaemic stroke.
  • Use of anticoagulants or antiplatelets.
  • Chronic kidney disease (CKD).

Signs and symptoms

Symptoms depend on the location and size of the haemorrhage.

General Features:

  • Sudden onset: rapid neurological deterioration.
  • Severe headache: common, but not always present.
  • Altered consciousness: confusion, drowsiness, or coma.
  • Vomiting: due to raised ICP.

Focal Neurological Deficits:

  • Hemiparesis: weakness on one side of the body.
  • Aphasia: difficulty with speech if in the dominant hemisphere.
  • Gaze deviation: eyes may deviate towards the side of the lesion.
  • Seizures: more common in lobar haemorrhages.
  • Brainstem involvement: can lead to abnormal respiration and pinpoint pupils.

Investigations

  • Urgent non contrast CT brain: first line imaging, shows hyperdense (bright) lesion.
  • CT angiography: consider if vascular malformation or aneurysm is suspected.
  • MRI brain: useful for underlying structural lesions (e.g., tumour, CAA).
  • Blood tests:
    • Full blood count (FBC): check for anaemia, infection.
    • Coagulation screen: important if on anticoagulants.
    • Renal function: CKD is a risk factor.
  • Electrocardiogram (ECG): to rule out cardiac causes of stroke.

Management

1. Emergency Resuscitation:

  • Secure airway if reduced consciousness.
  • Monitor and manage blood pressure (target SBP <140 mmHg).
  • Reverse anticoagulation if applicable:
    • Warfarin.
    • DOACs.

2. Neurosurgical Intervention:

  • Indicated if large haematoma causing mass effect.
  • Decompressive craniectomy in life-threatening cases.
  • Ventricular drainage if hydrocephalus develops.

3. Medical Management:

  • Control blood pressure (Labetalol, Nicardipine IV).
  • Seizure prophylaxis in selected cases.
  • Manage complications (e.g., aspiration pneumonia, DVT prophylaxis).

4. Long-Term Rehabilitation:

  • Physiotherapy for motor recovery.
  • Speech therapy for aphasia.
  • Occupational therapy for functional adaptation.
NeurologymypanotesIntracerebral Haemorrhage