How to Write Cause of Death in Intraparenchymal Bleeding
When documenting cause of death from intraparenchymal bleeding, specify the anatomic location (e.g., "intraparenchymal hemorrhage - basal ganglia"), the underlying etiology when known (e.g., hypertensive, traumatic, coagulopathic), and any contributing factors such as anticoagulation status or coagulopathy.
Essential Components of Death Certificate Documentation
Primary Cause of Death Statement
Use the term "intraparenchymal hemorrhage" or "intracerebral hemorrhage" rather than generic terms like "brain hemorrhage" or "stroke" to provide anatomic specificity 1, 2.
Specify the exact anatomic location: deep/ganglionic (basal ganglia, thalamus), lobar (frontal, parietal, temporal, occipital), cerebellar, or brain stem 1.
Include hemorrhage volume when available, as volumes >30 mL in supratentorial locations or >3 cm in cerebellar locations indicate higher mortality risk 3.
Underlying Etiology Documentation
The immediate cause should be followed by the underlying pathophysiological mechanism:
For hypertensive hemorrhages: Document as "intraparenchymal hemorrhage due to hypertensive vasculopathy" when located in typical deep locations (basal ganglia, thalamus, pons, cerebellum) 4, 1.
For coagulopathic hemorrhages: Specify "intraparenchymal hemorrhage due to [specific anticoagulant]" or "intraparenchymal hemorrhage due to coagulopathy secondary to [underlying condition]" 4.
For traumatic hemorrhages: Document as "traumatic intraparenchymal hemorrhage" to distinguish from spontaneous bleeding 4.
For structural lesions: Include "intraparenchymal hemorrhage secondary to [arteriovenous malformation/aneurysm/tumor/cerebral amyloid angiopathy]" when identified 4, 5.
Contributing Factors Section
Document relevant contributing conditions in the appropriate section of the death certificate:
Anticoagulation status (warfarin, direct oral anticoagulants, antiplatelet agents) 6, 7.
Coagulation disorders (thrombocytopenia, hemophilia, factor deficiencies) 4, 5.
Chronic hypertension as a contributing factor even if not the immediate cause 1.
Cerebral amyloid angiopathy for lobar hemorrhages in elderly patients 4, 5.
Mechanism of Death Documentation
Immediate Physiological Cause
Specify the terminal event that directly preceded death:
Transtentorial herniation secondary to mass effect from intraparenchymal hemorrhage 3.
Brainstem compression from cerebellar hemorrhage with obstructive hydrocephalus 3.
Elevated intracranial pressure refractory to medical management 8, 3.
Intraventricular extension with acute hydrocephalus when present 6.
Complications Leading to Death
Document secondary complications when they contributed to death:
Hemorrhagic expansion documented on follow-up imaging (specify volume increase of >6-12.5 mL or >20-33% relative increase) 4.
Seizures with status epilepticus 6.
Medical complications (aspiration pneumonia, pulmonary embolism, cardiac complications) 9.
Temporal Sequence Documentation
Time Course Specification
Document time from symptom onset to death, as this provides epidemiological data 3.
Note if death occurred within 24 hours (hyperacute phase), 24-72 hours (acute phase), or beyond 72 hours 4.
Specify if hemorrhage expansion was documented on follow-up imaging at 24 hours 4, 8.
Category Classification for Statistical Purposes
Distinguish Between Four Main Categories
The death certificate should allow classification into one of four categories for public health surveillance 4:
Noncoagulopathic spontaneous intraparenchymal hemorrhage - most commonly hypertensive 4.
Coagulopathic spontaneous intraparenchymal hemorrhage - related to anticoagulation or coagulation disorders 4.
Noncoagulopathic traumatic intraparenchymal hemorrhage 4.
Coagulopathic traumatic intraparenchymal hemorrhage 4.
Common Pitfalls to Avoid
Avoid using vague terms like "cerebrovascular accident" or "stroke" without specifying hemorrhagic nature and location 1, 2.
Do not omit anticoagulation status when present, as this is critical for epidemiological tracking and quality improvement 6, 7.
Do not list only "increased intracranial pressure" as the cause without specifying the underlying hemorrhage 8.
Avoid listing "coma" or "respiratory failure" as the primary cause when these are terminal events from the hemorrhage 9.
Do not use "intracerebral bleeding" and "intraparenchymal hemorrhage" interchangeably without recognizing that intracerebral hemorrhage specifically refers to bleeding within brain parenchyma, excluding subdural, epidural, or subarachnoid spaces 4, 1.
Severity Indicators to Include
Document objective severity measures when available: