What is a cerebral hemorrhage?

What is a Cerebral Hemorrhage?

A cerebral hemorrhage (also called intracerebral hemorrhage or ICH) is bleeding within the brain tissue itself, defined as evidence of blood in the brain on neuroimaging. 1

Definition and Pathophysiology

Cerebral hemorrhage is a type of stroke caused by bleeding into the brain parenchyma, accounting for approximately 10% of all strokes with a mortality rate of about 50%. 2 It represents a devastating neurological emergency characterized by:

• Acute blood accumulation within brain tissue that can be identified on CT imaging as high density consistent with acute blood, or on MRI with signal characteristics indicating recent hemorrhage 1
• Secondary brain damage from hematoma expansion and perihematoma edema following the initial bleed 3
• High rates of mortality and morbidity with substantial residual disability among survivors 4

Clinical Presentation

The American Heart Association identifies sudden onset of focal neurological deficits, severe headache, vomiting, and decreased level of consciousness or coma as common symptoms of intracranial hemorrhage. 5 Specifically:

• Rapid onset of focal neurological deficit with clinical signs of increased intracranial pressure is strongly suggestive of cerebral hemorrhage 3
• Elevated systolic blood pressure (often >220 mm Hg) is common and associated with hematoma expansion 5
• Specific clinical syndromes develop depending on hemorrhage location (deep gray nuclei, cerebellum, or pons) 2

Diagnostic Criteria

Rapid neuroimaging with CT or MRI is mandatory to distinguish cerebral hemorrhage from ischemic stroke, with CT being the gold standard for identifying acute hemorrhage. 5, 6 The diagnostic approach requires:

• CT head without IV contrast as first-line imaging (rated 9/9 by American College of Radiology) performed as soon as possible after symptom onset 6
• Evidence of acute blood with Hounsfield values consistent with recent hemorrhage on CT, ideally performed within 1 week of clinical event onset 1
• New high density on CT compared to previous imaging, or resolution on follow-up CT performed at least 2 weeks later 1

Common Etiologies

Hypertension accounts for approximately half of spontaneous cerebral hemorrhages; the remainder are due to tumors, aneurysms, vascular malformations, vasculopathies, and coagulation disorders. 2 Key causes include:

• Chronic arterial hypertension as the major risk factor 3
• Oral anticoagulation (warfarin-related hemorrhages associated with increased hematoma volume and mortality) 6
• Cerebral amyloid angiopathy particularly in lobar hemorrhages 7
• Antiplatelet therapy though specific management guidance is lacking 3

Critical Distinguishing Features

Brain imaging should be performed as soon as possible after onset of symptoms suspicious of hemorrhage, as clinical features alone cannot reliably differentiate hemorrhage from ischemia. 6 Important points:

• The mere existence of a hemosiderin halo or solely an increase in diameter without other evidence of recent hemorrhage does not constitute acute hemorrhage 1
• 28-38% of patients have hematoma expansion of greater than one-third on follow-up CT when initial imaging occurs within 3 hours of onset 6
• Follow-up imaging is recommended for abrupt neurological deterioration to evaluate for hematoma expansion 6

Prognostic Factors

The volume of cerebral hemorrhage and Glasgow Coma Scale score on admission are the most powerful predictors of 30-day mortality. 5 However:

• Most patients present with small hemorrhages that are readily survivable with good medical care, warranting early aggressive treatment 5
• Management in a specialist neurointensive care unit is associated with improved outcomes 3, 8