Hemorrhagic Stroke: Intracerebral Hemorrhage

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Original Editor - Lucinda hampton Top Contributors - Lucinda hampton, Kim Jackson, Tony Lowe and Dinu Dixon

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Introduction

15% of acute strokes are hemorrhagic strokes which are caused by bursting of a blood vessel i.e. acute hemorrhage. There are two main types of hemorrhagic strokes, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage which accounts for about 5% of all strokes. This page is about ICH ie bleeding within the brain tissue itself — a life-threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood supply. The image is od an ischaemic stroke (L) and Haemorrhagic stroke (R)

• Intracerebral hemorrhage (ICH) is a devastating event, carrying a very high morbidity and mortality rate that have not changed over the last 30 years.
• Hypertension and age-related amyloid angiopathy are the strongest risk factors for ICH, but smoking, anticoagulation with warfarin, excessive alcohol intake and cocaine also increase risk.
• At one year, mortality ranges from 51% to 65% depending on the location of the hemorrhage. Half of these deaths occur in the first two days and at six months, only 20% of patients are expected to be independent. 
• The incidence of hemorrhage increases exponentially with age and is higher in men than in women.

Clinically Relevant Anatomy

ICH are almost invariably associated with hypertension and are presumed by many to be the result of weakening of arterial walls by the trauma of an excessive pulse pressure. The most common sites of involvement are:

(1) the region of the putamen-external capsule in the distribution of the lenticulostriate branches of the middle cerebral artery (50%);

(2) the thalamus in the distribution of the small penetrating vessels from the posterior cerebral and posterior communicating arteries (10%);

(3) the cerebellum in the distribution of the deep penetrating branches of the superior cerebellar artery (10%); and

(4) the pons in the distribution of the paramedian branches of the basilar artery (10%).

The remaining 20% occur into the white matter of various lobes of the cerebral hemispheres.

Mechanism of Injury / Pathological Process

• Hypertensive vascular change - ICH is usually caused by ruptured vessels that are degenerated due to long-standing hypertension the arteries showing prominent degeneration of the media and smooth muscles. Less frequently fibrinoid necrosis of the sub-endothelium with micro-aneurysms and focal dilatations may occur.
• Cerebral amyloid angiopathy - CAA is characterized by the deposition of amyloid-β peptide at capillaries, arterioles, and small- and medium-sized arteries in the cerebral cortex, leptomeninges, and cerebellum . CAA in the cerebral small vessel leads to sporadic ICH in elderly people, commonly associated with variations in the gene encoding apolipoprotein E epsilon 2 and 4 in chromosome 19 . Duplication of the APP locus on chromosome 21 is also found in families with familial early-onset Alzheimer disease and CAA. CAA-related ICHs occur mainly in the elderly subjects while a rare familial syndrome may manifest in relatively young patients.
• Molecular pathophysiology - The initial injury mechanism in ICH is compressing brain parenchyma by hematoma’s mass effect, resulting in physical disruption of parenchymal architecture.

In aging individuals, and especially in those with Alzheimer's Disease, amyloid deposition may occur in the penetrating cortical vessels, making the vessels more friable and subject to hemorrhage. Typically, the hemorrhage is lobar (i.e., immediately subcortical) and the likelihood that amyloid angiopathy is the etiology of the hemorrhage is increased if there is no past history of hypertension.

Risk Factors

Risk factors of intracerebral hemorrhage

Modifiable risk factors

Hypertension

Current smoking

Excessive alcohol consumption

Decreased Low-density lipoprotein cholesterol, low triglycerides

Anticoagulation

Use the antiplatelet agent

Sympathomimetic drugs (Cocaine, heroin, amphetamine, PPA and ephedrine)

Non-modifiable risk factor

Old age

Male sex

Asian ethnicity

Cerebral amyloid angiopathy

Cerebral microbleeds

Chronic kidney disease

Other factors suggested to be related the risk

Multi-parity

Poor working conditions (blue-collar occupation, longer working time)

Clinical Presentation

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Diagnostic Procedures

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Outcome Measures

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Management / Interventions

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Differential Diagnosis

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Resources

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