Intracerebral haemorrhage

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Spontaneous intracerebral haemorrhage is a common presentation of stroke disease. This article will not consider traumatic intracerebral haemorrhage.

Contents

Haemorrhagic stroke

This is the major differential diagnosis between ischaemic or embolic stroke and where patients have easy access to CT head scanners is simple to exclude soon after presentation. The epidemiology is well understood. While in most western countries it makes up between 10% to 15% of all strokes this is much higher in Asia. Treating hypertension has had a major impact on incidence. However after the fact, it remains without a pharmacological treatment of proven benefit.

Risk factors

Prognosis

This depends upon the size of the haemorrhage and its position. Mortality at 3 months is about a third with 30% regained independent functional status after 3 months[2] and long term studies report worse outcomes than this[3]. Growth of the haematoma after presentation worsens prognosis. Infratentorial haematomas greater than 20mls have a particularly bad prognosis. Being on warfarin therapy rather than aspirin increases 28 day mortality by 23%[4]. While high dose atorvastatin increases the risk of haemorrhagic stroke, being on a statin appears protective[5], possibly by lowering relative oedema[6]. Indeed relative (not absolute) oedema is a poor prognostic measure[7] although the amount of oedema in patients on warfarin predicts better morbidity outcome in the survivors [8].

LogoKeyPointsBox.pngMortality is predicted independently by[9]:
  • Age
  • Glasgow coma scale
  • Haemorrhage into the ventricular system
  • Haematoma volume
  • Infratentorial haematoma

Prognostic scores

Several prognostic scores exist:

Treatment

There is some evidence for early BP control. Care is supportive and during the recovery phase there is good evidence for multidisciplinary stroke care. It is unknown if the benefit of organised acute care for ischaemic stroke translates into benefit for haemorrhagic stroke but some evidence that early aggressive care without early do not resuscitate orders might improve mortality outcome[13].

The following are likely to be ineffective or harmful:

The following are unlikely to be benefical:

Investigational approaches include:

  • Recombinant activated factor VII (rFVIIa) [17][18] but this causes thromboembolism[19] and the evidence for net benefit remains conflicting[20].

This article is a work in progress. Please feel free to contribute to it.


References

  1. Goldstein LB, Amarenco P, Szarek M, Callahan A, Hennerici M, Sillesen H, Zivin JA, Welch KM. Hemorrhagic stroke in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels study. . 2007 Dec 12.(Epub ahead of print) (Link to article – subscription may be required.)
  2. Weimar C, Weber C, Wagner M, Busse O, Haberl RL, Lauterbach KW, Diener HC. Management patterns and health care use after intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany. Cerebrovascular diseases (Basel, Switzerland). 2003; 15(1-2):29-36.
  3. McGuire AJ, Raikou M, Whittle I, Christensen MC. Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study. Cerebrovascular diseases (Basel, Switzerland). 2007; 23(2-3):221-8.(Link to article – subscription may be required.)
  4. Hanger HC, Fletcher VJ, Wilkinson TJ, Brown AJ, Frampton CM, Sainsbury R. Effect of aspirin and warfarin on early survival after intracerebral haemorrhage. Journal of neurology. 2008 Mar; 255(3):347-52.(Link to article – subscription may be required.)
  5. Naval NS, Abdelhak TA, Zeballos P, Urrunaga N, Mirski MA, Carhuapoma JR. Prior statin use reduces mortality in intracerebral hemorrhage. Neurocritical care. 2008; 8(1):6-12.(Link to article – subscription may be required.)
  6. Naval NS, Abdelhak TA, Urrunaga N, Zeballos P, Mirski MA, Carhuapoma JR. An association of prior statin use with decreased perihematomal edema. Neurocritical care. 2008; 8(1):13-8.(Link to article – subscription may be required.)
  7. Gebel JM, Jauch EC, Brott TG, Khoury J, Sauerbeck L, Salisbury S, Spilker J, Tomsick TA, Duldner J, Broderick JP. Relative edema volume is a predictor of outcome in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke; a journal of cerebral circulation. 2002 Nov; 33(11):2636-41.
  8. Levine JM, Snider R, Finkelstein D, Gurol ME, Chanderraj R, Smith EE, Greenberg SM, Rosand J. Early edema in warfarin-related intracerebral hemorrhage. Neurocritical care. 2007; 7(1):58-63.(Link to article – subscription may be required.)
  9. Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla-Martínez JJ, González-Cornejo S. Grading scale for prediction of outcome in primary intracerebral hemorrhages. Stroke; a journal of cerebral circulation. 2007 May; 38(5):1641-4.(Link to article – subscription may be required.)
  10. Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke; a journal of cerebral circulation. 2001 Apr; 32(4):891-7.
  11. Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla-Martínez JJ, González-Cornejo S. Grading scale for prediction of outcome in primary intracerebral hemorrhages. Stroke; a journal of cerebral circulation. 2007 May; 38(5):1641-4.(Link to article – subscription may be required.)
  12. Weimar C, Benemann J, Diener HC. Development and validation of the Essen Intracerebral Haemorrhage Score. Journal of neurology, neurosurgery, and psychiatry. 2006 May; 77(5):601-5.(Link to article – subscription may be required.)
  13. Zahuranec DB, Brown DL, Lisabeth LD, Gonzales NR, Longwell PJ, Smith MA, Garcia NM, Morgenstern LB. Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology. 2007 May 15; 68(20):1651-7.(Link to article – subscription may be required.)
  14. Ogun SA, Odusote KA. Effectiveness of high dose dexamethasone in the treatment of acute stroke. West African journal of medicine. 2001 Jan-Mar; 20(1):1-6.
  15. Bereczki D, Fekete I, Prado GF, Liu M. Mannitol for acute stroke. Cochrane database of systematic reviews (Online). 2007; (3):CD001153.(Epub) (Link to article – subscription may be required.)
  16. Leonardi-Bee J, Steiner T, Bath-Hextall F. Naftidrofuryl for acute stroke. Cochrane database of systematic reviews (Online). 2007; (2):CD005478.(Epub) (Link to article – subscription may be required.)
  17. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T. Recombinant activated factor VII for acute intracerebral hemorrhage. The New England journal of medicine. 2005 Feb 24; 352(8):777-85.(Link to article – subscription may be required.)
  18. Wartenberg KE, Mayer SA. Reducing the risk of ICH enlargement. Journal of the neurological sciences. 2007 Oct 15; 261(1-2):99-107.(Link to article – subscription may be required.)
  19. Diringer MN, Skolnick BE, Mayer SA, Steiner T, Davis SM, Brun NC, Broderick JP. Risk of thromboembolic events in controlled trials of rFVIIa in spontaneous intracerebral hemorrhage. Stroke; a journal of cerebral circulation. 2008 Mar; 39(3):850-6.(Link to article – subscription may be required.)
  20. Hallevi H, Gonzales NR, Barreto AD, Martin-Schild S, Albright KC, Noser EA, Illoh K, Khaja AM, Allison T, Escobar MA, Shaltoni HM, Grotta JC. The effect of activated factor VII for intracerebral hemorrhage beyond 3 hours versus within 3 hours. Stroke; a journal of cerebral circulation. 2008 Feb; 39(2):473-5.(Link to article – subscription may be required.)
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