From the Guidelines
The prognosis of intracerebral hemorrhage (ICH) is generally poor, with high rates of early mortality and significant persistent functional deficits. According to the most recent guidelines, approximately 25-50% of patients die within the first 30 days 1. Several factors influence outcomes, including hemorrhage volume, location, presence of intraventricular extension, patient age, and initial Glasgow Coma Scale score.
Key Factors Influencing Outcomes
- Hemorrhage volume: volumes >30 mL indicate worse prognosis
- Location: deep hemorrhages in the basal ganglia, thalamus, or brainstem have poorer outcomes than lobar hemorrhages
- Presence of intraventricular extension: doubles mortality
- Patient age: worse outcomes in older patients
- Initial Glasgow Coma Scale score: lower scores correlate with higher mortality The ICH score, which incorporates these factors, helps predict 30-day mortality.
Management
Management focuses on:
- Blood pressure control: targeting systolic BP <140 mmHg within 2 hours of onset
- Reversal of anticoagulation if applicable: using prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, or andexanet alfa for factor Xa inhibitors 1
- Prevention of complications
- Supportive care Surgical evacuation may benefit select patients with superficial hemorrhages or cerebellar hemorrhages >15 mL with neurological deterioration 1.
Rehabilitation and Recovery
Recovery typically occurs over 3-6 months, with most improvement in the first few weeks. Survivors require comprehensive rehabilitation and secondary prevention measures, including strict blood pressure management and lifestyle modifications.
Recent Guidelines
Recent guidelines recommend coordinated multidisciplinary care with early assessment of discharge planning and a goal of early supported discharge for mild to moderate ICH 1. Implementation of rehabilitation activities such as stretching and functional task training may be considered 24 to 48 hours after moderate ICH.
From the Research
Prognosis of Intracerebral Hemorrhage
- Intracerebral hemorrhage (ICH) is a devastating type of stroke with a high mortality rate and poor functional outcome in survivors 2, 3, 4.
- The prognosis of ICH is influenced by various factors, including the size and location of the hematoma, the patient's age, and the presence of underlying medical conditions 2, 5.
- Clinical grading systems, such as the ICH scale, have been developed to help stratify patients with ICH and predict prognosis 2, 6.
- However, the use of these scales may be limited by the inclusion of patients who have care withdrawn, which can lead to a self-fulfilling prophecy of poor outcome 2.
- Recent studies have shown that early interventions, such as aggressive blood pressure control and minimally invasive surgery, may improve outcomes in patients with ICH 3, 5, 4.
- The prognosis of ICH can be affected by the timing of care withdrawal, with most patients having care withdrawn within the first two hospital days 2.
- Current guidelines suggest waiting more than 24 hours before deciding to withdraw care, in order to allow for the potential benefits of early interventions to be realized 2.
Mortality and Disability
- Mortality rates for ICH are high, with significant variability depending on the severity of the hemorrhage and the patient's underlying medical conditions 2, 3, 4.
- Disability is also a common outcome in survivors of ICH, with many patients experiencing significant cognitive and functional impairment 3, 4.
- The ICH Score is a commonly used tool to predict mortality and disability in patients with ICH, but its accuracy may be limited by the inclusion of patients who have care withdrawn 6.
- Recent studies have shown that the ICH Score may overestimate mortality for low-grade and moderate-grade hemorrhages, but underpredict severe disability 6.
Management and Treatment
- The management of ICH typically involves supportive care, including control of blood pressure, reversal of anticoagulant effects, and management of increased intracranial pressure 3, 5, 4.
- Surgical evacuation of the hematoma may be considered in selected patients, but its benefits are still uncertain 3, 5, 4.
- Minimally invasive techniques for hematoma evacuation are being developed and may offer a valuable approach to improving outcomes in patients with ICH 3, 5, 4.