- Clinical science
Intracerebral hemorrhage (ICH) refers to bleeding within the brain parenchyma. The term should not be confused with “intracranial hemorrhage,” which encompasses any type of bleeding within the skull, i.e., extradural, subdural, subarachnoid, and intracerebral. The most significant risk factor for spontaneous ICH is arterial hypertension. Symptoms are often nonspecific (e.g., headache), but, depending on the affected vessel and cerebral region, focal neurologic deficits (e.g., hemiparesis) may occur. Compared to ischemic stroke, patients with ICH typically present with more severe headache and symptoms usually progress more rapidly. A noncontrast head CT, the most important diagnostic procedure, shows a hyperdense lesion in acute ICH and a hypodense lesion in hyperacute ICH. Treatment involves management of the underlying and accompanying conditions (e.g., controlling hypertension, reversing coagulopathy) and, in severe cases, neurosurgical intervention. Approximately half of patients with ICH die within 30 days.
- Intracranial hemorrhage: a broad term used to describe any bleeding within the skull (including intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage) due to traumatic brain injury or nontraumatic causes (e.g., hemorrhagic stroke, ruptured aneurysm, hypertensive vasculopathy)
- Hemorrhagic stroke
- ICH is responsible for approx. 10% of all strokes. 
- Most commonly affects the deep structures of the brain 
- Intraventricular extension occurs in approx. 30% of patients with ICH. 
Epidemiological data refers to the US, unless otherwise specified.
- Hypertension: most common cause of spontaneous ICH
- Cerebral amyloid angiopathy: most common cause of spontaneous ICH in individuals > 60 years of age
- Arteriovenous malformations: most common cause of spontaneous intracerebral hemorrhage in children
- Vasculitis (e.g., giant cell arteritis)
- Neoplasms (e.g., meningioma)
- Ischemic stroke (due to reperfusion injury)
- CNS infections (e.g., HSV encephalitis)
- Septic emboli
- Coagulopathy (e.g., hemophilia, anticoagulant use)
- Stimulant use (e.g., cocaine and amphetamines; possibly also caffeine)
- Traumatic: : see
Nontraumatic mechanisms of hemorrhage
- Chronic arterial hypertension → lipohyalinosis of lenticulostriate vessels, which supply the basal ganglia → formation and rupture of Charcot-Bouchard microaneurysms → lacunar strokes (ischemia) of the basal ganglia
- Cerebral amyloid angiopathy: deposition of β-amyloid peptides in vessel walls → focal damage with formation of microaneurysms → rupture → recurrent lobar intracerebral hemorrhage
- Structural abnormalities (e.g., vascular malformations) → exposure of parts of the abnormal vascular segment to excessive strain → rupture
- Venous outflow obstruction and stimulant use (e.g., cocaine) → acute arterial hypertension
- Coagulopathies: impaired hemostasis → vascular microtrauma
- Inflammatory tissue necrosis → damage to vessels
- Traumatic: blunt or penetrating injury → damage to vessels
- Absent in small hemorrhages
- Most common in cerebellar and lobar hemorrhages 
- Focal neurologic signs and symptoms may occur, depending on the location and size of the hemorrhage (see and in )
- Immediate noncontrast head CT
- Diffusion-weighted MRI
- Laboratory studies
- Angiography (e.g., CTA and/or MRA): to identify the source of the bleeding if the patient does not have any risk factors
Medical therapy 
- Reverse anticoagulation
- Blood pressure management 
- Maintain euvolemia
- Avoid/treat hyponatremia
- Maintain normoglycemia
- If there are signs of elevated ICP (e.g., Cushing triad)
- Antiepileptic drugs: for seizures
Surgical therapy 
Craniotomy and clot evacuation
- Patients with hemorrhage in the basal ganglia or the internal capsule should generally not undergo surgical clot removal. 
- If hydrocephalus is present: ventricular drain, serial LPs, or permanent ventriculoperitoneal shunt may be indicated
Patients with signs of brain herniation should be operated on immediately!
- Urgent neurosurgery consult
- Airway management: Consider anesthesiology consult.
- Identify and treat any underlying coagulopathy. 
- Blood pressure management: Lower systolic blood pressure to 140 mm Hg with intravenous antihypertensive medication.  
- mannitol.  : Consider
- Identify and treat the underlying cause: Consider further imaging (e.g., CT angiography ).
- Admit to neurosurgical ICU.
- Start intermittent pneumatic compression of the legs. 
Approximately 50% of all patients with ICH die within 30 days.