How should I complete a death certificate for a patient who died from an intracranial hemorrhage, including immediate cause, underlying cause, manner of death, and appropriate ICD‑10 codes?

Completing a Death Certificate for Intracranial Hemorrhage

When a patient dies from intracranial hemorrhage, document it as either the immediate cause of death (Part I, line a) if death occurred directly from the hemorrhage, or as the underlying cause (Part I, line c or d) if complications such as herniation or increased intracranial pressure were the immediate causes. 1

Immediate Cause of Death (Part I, Line a)

The immediate cause should reflect the final event that directly caused death:

• Cerebral herniation (if herniation was the terminal event) 2, 3
• Increased intracranial pressure (if ICP elevation caused death) 3, 4
• Brainstem compression (if this was the mechanism) 4
• Respiratory failure secondary to brainstem herniation 3, 4

Underlying Cause of Death (Part I, Lines b-d)

Work backward from the immediate cause to the underlying pathology:

• Line b: "Intracranial hemorrhage" or specify the type:

  • Intracerebral hemorrhage (specify location: lobar, deep, cerebellar, brainstem) 1, 5
  • Subarachnoid hemorrhage 5, 6
  • Subdural hematoma 1, 5
  • Intraventricular hemorrhage 6

• Line c or d: Document the etiology when known:

  • Hypertensive hemorrhage 3, 5, 7
  • Cerebral amyloid angiopathy 3, 7
  • Ruptured cerebral aneurysm 5, 6
  • Arteriovenous malformation 5, 6
  • Anticoagulant therapy (specify agent: warfarin, NOAC) 3, 7
  • Hemorrhagic transformation of ischemic stroke 5, 6

Cardiovascular Classification

The ACC/AHA Task Force classifies cerebral hemorrhage as a specific cardiovascular cause of death under "CV: CV hemorrhage," defined as "death related to hemorrhage such as a nonstroke intracranial hemorrhage (e.g., subdural hematoma), nonprocedural or nontraumatic vascular rupture." 2, 1

ICD-10 Coding

Select the appropriate code based on hemorrhage type and location:

• I61.x for intracerebral hemorrhage (specify location with fourth digit) 1, 5
• I60.x for subarachnoid hemorrhage 5, 6
• I62.x for other nontraumatic intracranial hemorrhage (subdural, extradural) 1, 5
• Add secondary codes for underlying conditions (I10 for hypertension, etc.) 7

Manner of Death

• Natural for spontaneous hemorrhages from hypertension, cerebral amyloid angiopathy, aneurysms, or vascular malformations 5, 7
• Accident if hemorrhage resulted from trauma (even if delayed) 6
• Could not be determined if anticoagulation was therapeutic but hemorrhage occurred (this varies by jurisdiction) 7

Essential Documentation Elements

Confirm the diagnosis with neuroimaging (CT or MRI) whenever possible and reference the imaging in your documentation. 1, 6 The American Heart Association emphasizes that imaging confirmation strengthens the death certificate's accuracy. 1

Document the specific anatomical location (lobar, deep structures, cerebellar, brainstem) as this provides critical epidemiological data. 1, 5 Location affects both clinical presentation and outcome, with infratentorial hemorrhages having particularly high mortality. 4, 7

Include timing information: Note the interval from symptom onset to death, as most deaths occur within the first 24-72 hours when hematoma expansion and secondary brain injury are most active. 3, 4

Common Pitfalls to Avoid

• Do not list "stroke" alone without specifying hemorrhagic versus ischemic type, as this obscures critical epidemiological distinctions. 1, 5
• Do not omit anticoagulation status if relevant, as anticoagulation-related ICH is increasing and represents a distinct clinical entity requiring separate tracking. 7
• Do not confuse traumatic and spontaneous hemorrhage in your documentation, as these have different ICD-10 codes and public health implications. 5, 6
• Do not list only "intracranial hemorrhage" without specifying the compartment (intraparenchymal, subarachnoid, subdural, etc.), as the ACC/AHA standards require this specificity. 2, 1