Intracranial Hemorrhage

11/16/13 Intracranial Hemorrhage

emedicine.medscape.com/article/1163977-overview#a0104 1/7

Intracranial Hemorrhage

Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more...

Updated: Jan 23, 2013

Background

Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may occur within brainparenchyma or the surrounding meningeal spaces. Hemorrhage within the meninges or the associated potentialspaces, including epidural hematoma, subdural hematoma, and subarachnoid hemorrhage, is covered in detail inother articles. Intracerebral hemorrhage (ICH) and extension of parenchymal bleeding into the ventricles (ie,intraventricular hemorrhage [IVH]) are detailed here.

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders.Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoidhemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue,leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation ofintracranial pressure (ICP) and potentially fatal herniation syndromes.

Pathophysiology

Nontraumatic intracerebral hemorrhage most commonly results from hypertensive damage to blood vessel walls(eg, hypertension, eclampsia, drug abuse), but it also may be due to autoregulatory dysfunction with excessivecerebral blood flow (eg, reperfusion injury, hemorrhagic transformation, cold exposure), rupture of an aneurysm orarteriovenous malformation (AVM), arteriopathy (eg, cerebral amyloid angiopathy, moyamoya), altered hemostasis(eg, thrombolysis, anticoagulation, bleeding diathesis), hemorrhagic necrosis (eg, tumor, infection), or venousoutflow obstruction (eg, cerebral venous thrombosis). Nonpenetrating and penetrating cranial trauma are alsocommon causes of intracerebral hemorrhage.

Chronic hypertension produces a small vessel vasculopathy characterized by lipohyalinosis, fibrinoid necrosis,and development of Charcot-Bouchard aneurysms, affecting penetrating arteries throughout the brain includinglenticulostriates, thalamoperforators, paramedian branches of the basilar artery, superior cerebellar arteries, andanterior inferior cerebellar arteries.

Predilection sites for intracerebral hemorrhage include the basal ganglia (40-50%), lobar regions (20-50%),thalamus (10-15%), pons (5-12%), cerebellum (5-10%), and other brainstem sites (1-5%).

Intraventricular hemorrhage occurs in one third of intracerebral hemorrhage cases from extension of thalamicganglionic bleeding into the ventricular space. Isolated intraventricular hemorrhage frequently arise fromsubependymal structures including the germinal matrix, AVMs, and cavernous angiomas.

Epidemiology

Frequency

United States

Each year, intracerebral hemorrhage affects approximately 12-15 per 100,000 individuals, including 350

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hypertensive hemorrhages per 100,000 elderly individuals. The overall incidence of intracerebral hemorrhage hasdeclined since the 1950s.

International

Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the world.

Mortality/Morbidity

Annually, more than 20,000 individuals in the United States die of intracerebral hemorrhage. Intracerebralhemorrhage has a 30-day mortality rate of 44%. Pontine or other brainstem intracerebral hemorrhage has amortality rate of 75% at 24 hours. Hallevi et al reviewed the charts and CT scans of patients with intraventricularhemorrhage (IVH) to determine if the extension of the hemorrhage could be measured. Clinical outcome wasdetermined by the modified Rankin Scale (mRS). IVH was also classified with an IVH score. The IVH score

allowed rapid estimate of IVH volume by the practitioner and increased predictability for outcome.[1]

Race

Intracerebral hemorrhage has a higher incidence among populations with a higher frequency of hypertension,including African Americans. A higher incidence of intracerebral hemorrhage has been noted in Chinese,Japanese, and other Asian populations, possibly due to environmental factors (eg, a diet rich in fish oils) and/orgenetic factors.

Sex

Intracerebral hemorrhage has a slight male predominance, though study results have been conflicting.

Cerebral amyloid angiopathy may be more common among women.

Phenylpropanolamine use has been associated with intracerebral hemorrhage in young women.[2]

Age

Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decadeuntil age 80 years. The relative risk of intracerebral hemorrhage is greater than 7 in individuals older than 70 years.

In individuals younger than 45 years, lobar hemorrhage is the most common site of and frequently is associatedwith AVMs.

Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in premature infants.

Contributor Information and DisclosuresAuthorDavid S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program,University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke ImagingProgram, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA StrokeCenter

David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology,American Heart Association, American Medical Association, American Society of Neuroimaging, AmericanSociety of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Specialty Editor BoardJeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University ofCalifornia, Los Angeles, David Geffen School of Medicine

Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy ofNeurology, American Heart Association, American Neurological Association, and National Stroke Association



Disclosure: University of California The University of California Regents receive funds for consulting services on

clinical trial design provided to Telecris, Ev3, and CoAxia. Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical CenterCollege of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, ViceChairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt StrokeCenter; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff,Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Neurology, American Heart Association, American Medical Association, American NeurologicalAssociation, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, andTennessee Medical Association

Disclosure: Nothing to disclose.

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurologyand Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology,American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American EpilepsySociety, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting;Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting;Sleepmed/DigiTrace Honoraria Speaking, consulting; Sunovion Consulting fee None

Chief EditorHelmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and ScienceUniversity School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology andAmerican Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panelmembership; Concentric Medical Consulting fee Review panel membership

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Intracranial Hemorrhage