intracerebral%20hemorrhage
INTRACEREBRAL HEMORRHAGE
Intracerebral hemorrhage is the sudden burst of blood into the brain tissue itself.
It causes sudden onset of focal neurological deficit.
The focal neurologic findings are related to the anatomic location, size and speed of development of intracerebral hemorrhage.
Neurological deficit usually progresses over a minute to an hour.
Rapid recognition and diagnosis of intracerebral hemorrhage are essential because of its frequently rapid progression.

History

  • Assess presenting symptoms and associated activities at onset
  • Determine time of stroke onset and age

Physical Examination

  • Vital signs
  • General examination of the head, heart, lungs, abdomen and extremities
  • Brief but through neurologic exam [eg National Institute of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS)]

Laboratory Tests

  • Complete blood count (CBC), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (aPTT), electrolytes, blood urea nitrogen (BUN), creatinine, glucose
  • Urinalysis
  • Echocardiography (ECG), chest X-ray
  • Toxicology screen to rule out illicit drug use (eg cocaine, methamphetamine)

Imaging

  • The earlier time from onset of neurological symptoms to initial neuroimage, the more likely succeeding neuroimages will show hematoma expansion
  • Hematoma expansion is predictive of clinical deterioration, and increased morbidity and mortality

Plain Cranial Computed Tomography (CT) Scan & Contrast-Enhanced Computed Tomography (CT) Scan

  • CT scan differentiates ischemic stroke from intracerebral hemorrhage (ICH)
    • Scan will also show size, location and volume of hemorrhage
    • Intracerebral hemorrhage volume >30 mL has exponential risk with mortality
    • May reveal structural abnormalities (eg aneurysms, brain tumors) which may have caused intracerebral hemorrhage, or structural complications (eg herniation, hydrocephalus, intraventricular hemorrhage)
    • Contrast-enhanced CT scan is useful in identifying patients at high risk of hematoma expansion

Cranial Magnetic Resonance Imaging (MRI)

  • Equivalent to CT scan in determining the presence, size, location, and progression of acute intracerebral hemorrhage
  • Superior at detecting underlying structural lesions or tumor, delineating the amount of perihematomal edema and herniation and multiple old hemorrhages or microbleeds that suggest amyloid angiopathy
  • Used to check venous thrombosis, hemorrhages in high convexity, often bilateral and substantial edema

Angiography

  • CT angiography is useful in detecting hematoma expansion (spot sign)
  • Consider for all patients without clear cause of hemorrhage who are surgical candidates
    • Eg young, normotensive patients who are clinically stable
    • Useful in diagnosing secondary causes of intracerebral hemorrhage (eg aneurysm, arteriovenous malformation, venous sinus thrombosis, arteriovenous dural fistulae, vasculitis)
  • Angiography not required in older hypertensive patients who have hemorrhage in basal ganglia, cerebellum, thalamus, or brain stem and in whom CT does not show structural lesion
  •  Patient’s clinical state and neurologist/neurosurgeon’s discretion will determine the urgency and timing of angiography
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