From the Guidelines
Lobar hemorrhages are most commonly caused by hypertension, cerebral amyloid angiopathy, vascular malformations, tumors, or coagulopathies, and management should prioritize immediate stabilization, reversal of anticoagulation, and addressing underlying causes to reduce morbidity, mortality, and improve quality of life. The causes of lobar hemorrhages can be multifactorial, including:
- Hypertension, which is a common cause of deep hemorrhages but can also contribute to lobar hemorrhages, especially in hypertensive patients 1
- Cerebral amyloid angiopathy, particularly in elderly patients, which is often associated with lobar hemorrhages 1
- Vascular malformations, such as arteriovenous malformations or aneurysms, which can be identified using imaging studies like CT angiography or MRI 1
- Tumors, which can cause bleeding due to tumor necrosis or vascular invasion 1
- Coagulopathies, including those caused by anticoagulant medications like warfarin or direct oral anticoagulants 1
Management of lobar hemorrhages should focus on:
- Immediate stabilization of the patient, including airway protection, blood pressure control, and reversal of anticoagulation if applicable 1
- Medications to control blood pressure, such as labetalol, nicardipine, or clevidipine, and reversal agents for anticoagulants like vitamin K, prothrombin complex concentrate, idarucizumab, or andexanet alfa 1
- Surgical evacuation for large hemorrhages or those causing significant mass effect, and supportive care to manage increased intracranial pressure, prevent seizures, and prevent complications like deep vein thrombosis and aspiration pneumonia 1
- Long-term management to address underlying causes, including strict blood pressure control and lifestyle modifications to prevent recurrence 1
From the Research
Causes of Lobar Hemorrhages
- Hypertension is a common cause of lobar hemorrhages, as seen in 60% of patients in a study by 2
- Non-hypertensive causes include:
- Amyloid angiopathy, found in 6 patients in a study by 2 and 24 patients in a study by 3
- Aneurysms, found in 5 patients in a study by 2
- Arteriovenous malformation (AVM), found in 4 patients in a study by 2 and 6 patients in a study by 4
- Use of anticoagulants, found in 2 patients in a study by 2
- Liver cirrhosis, found in 2 patients in a study by 2
- Thrombasthenia, found in 1 patient in a study by 2
- Cerebral amyloid angiopathy-related inflammation, suggested as a possible cause of recurrent lobar hemorrhage in a case presentation by 5
Management of Lobar Hemorrhages
- Surgical evacuation of the hematoma may be considered in some cases, but is inadvisable in cases of amyloid angiopathy due to the diffuse nature of the condition and high recurrence rate, as noted in a study by 6
- Corticosteroid therapy may be considered in patients with recurrent lobar intracerebral hemorrhage in the setting of cerebral amyloid angiopathy, as suggested in a case presentation by 5
- The underlying cause of the lobar hemorrhage should be determined in order to guide management, as different causes may require different treatments, as seen in a study by 4
- Subarachnoid extension of the hematoma on CT scans may indicate a non-hypertensive cause, such as vascular abnormalities, as noted in a study by 2 and 4