Can an intracranial hemorrhage (ICH) cause cardiac arrest?

From the Guidelines

Intracranial bleeding can cause cardiac arrest, particularly when it occurs in the brainstem or leads to significant increased intracranial pressure, disrupting the brain's autonomic control centers that regulate heart function. This is supported by the guidelines for the management of spontaneous intracerebral hemorrhage from the American Heart Association/American Stroke Association 1, 2. When severe intracranial hemorrhage occurs, it can trigger a cascade of events including severe hypertension followed by hypotension, cardiac arrhythmias, and in extreme cases, cardiac arrest. The mechanism involves what's called neurogenic stunned myocardium, where catecholamine surges damage the heart muscle.

Key Points to Consider

• The risk of cardiac arrest from intracranial bleeding increases with the severity and location of the bleed, particularly those affecting the brainstem or causing significant midline shift 2.
• Management focuses on immediate neurosurgical intervention when appropriate, along with supportive care including airway management, blood pressure control, and treatment of increased intracranial pressure.
• Neuroimaging, such as CT and MRI, is crucial for diagnosing and managing intracranial hemorrhage, with CT being the gold standard for identifying acute hemorrhage 2.
• Hematoma expansion is a significant concern, occurring in 28–38% of patients undergoing head CT within 3 hours of ICH onset, and is predictive of clinical deterioration and increased morbidity and mortality 2.

Clinical Implications

• Early recognition and aggressive management of intracranial hemorrhage are critical to preventing cardiac arrest and improving patient outcomes.
• Clinicians should be aware of the potential for cardiac complications, including cardiac arrest, in patients with severe intracranial hemorrhage, and monitor them closely.
• The use of neuroimaging and other diagnostic tools can help identify patients at high risk of hematoma expansion and cardiac complications, allowing for targeted interventions.

From the Research

Relationship Between Intracranial Bleed and Cardiac Arrest

• Intracranial hemorrhage (ICH) is a known but rare cause of out-of-hospital cardiac arrest (OHCA) 3.
• The mechanism by which ICH patients develop cardiac arrest is likely explained by a massive catecholamine surge leading to cardiac stunning 3.
• A non-shockable rhythm in the setting of a sudden cardiac arrest should raise alarms for a primary non-cardiac etiology, especially a primary cerebrovascular event 3.

Types of Intracranial Bleeds Associated with Cardiac Arrest

• Subarachnoid hemorrhage is the leading neurologic cause of cardiac arrest, followed by intracerebral hemorrhage 4.
• Cerebellar hemorrhage leading to cardiac arrest is rare, but has been documented in case studies 3.
• Other neurologic diseases, such as epileptic seizure and ischemic stroke, can also cause cardiac arrest 4.

Outcomes and Prognosis

• Patients with cardiac arrest caused by a neurologic event have a very poor prognosis, with only 14% of patients alive at follow-up after 6 months 4.
• The most common cause of cardiac arrest in neurologic patients is subarachnoid hemorrhage, which has a high mortality rate 4.
• The choice of antihypertensive agent may affect outcomes in patients with intracerebral hemorrhage, with nicardipine associated with lower diastolic blood pressure compared to labetalol 5.