Acute Evaluation and Management of Intracerebral Hemorrhage

PURPOSE: Decisions regarding the acute management of intracerebral hemorrhage (ICH) are largely dependent upon the etiology, location, and size of the hemorrhage, as well as the clinical status of the patient. The purposes of this guidelines are to:

Provide prognostic information based on clinical status, ICH location, and ICH size:
Describe the likely etiologies of ICH;
Define the typical locations of hypertensive ICH;
Recommend the best medical treatments of ICH;
Identify the role of surgical treatment of ICH.

TYPES OF ICH

HYPERTENSIVE ICH
The 6 main locations of hypertensive ICH are: putamen, subcortical cerebral lobe, thalamus, cerebellum, brainstem, and caudate nucleus.
Each location may differ in clinical presentation, prognosis, and consideration for surgical treatment.

Putaminal Hemorrhage
The clinical presentation of putaminal hemorrhage may vary from relatively minor pure motor hemiparesis to profound weakness, sensory loss, eye deviation, hemianopsia, aphasia, and depressed level of consciousness (19,46). In this type of hematoma, intraventricular extension portends a poor prognosis, because the hematoma must be quite large to track through the internal capsule and reach the ventricle (50).

Lobar Hemorrhage
Although hypertension is a common cause of cerebral lobar hemorrhage, a variety of other etiologies must be considered (6). This is the most common location for ICH due to vascular malformation, tumor, and amyloid angiopathy (22,60). Clinical symptoms of lobar ICH depend largely on the location of the hemorrhage; for example, dominant lobe temporal hematomas may present with aphasia, and occipital hematomas may present with homonymous hemianopsia (23,41,58). Further evaluation, such as angiography, needs to be considered in the context of the clinical presentation and CT findings. A significant role for surgery may exist in the treatment of certain lobar hematomas.

Thalamic Hemorrhage
Thalamic hemorrhage often presents with contralateral sensory loss. Due to the proximity of the internal capsule, motor defects are also quite common. Pupil and extraocular movement defects may also be seen (3,56). Intraventricular hemorrhage or obstructive hydrocephalus may occur (54).

Cerebellar Hemorrhage
Cerebellar hemorrhage typically presents with abrupt onset of vertigo, headache, vomiting, and inability to walk without hemiparesis. Cranial nerve palsies may be associated (12). This type of hemorrhage may act as a posterior fossa mass, producing hydrocephalus and/or brainstem compression, and is the most amenable to acute surgical intervention.

Brainstem Hemorrhage
Presentation of brainstem hemorrhage may be coma, posturing, loss of brainstem reflexes, and oculomotor abnormalities. It most commonly involves the pons and generally has a dismal prognosis (27).

Caudate Hemorrhage
Hemorrhage into the caudate nucleus is rare. Because extension into the adjacent lateral ventricle usually occurs, the most common presentation is that of a primary intraventricular hemorrhage. Prognosis is generally good (57).

NON-HYPERTENSIVE ICH
Not all ICH is due to hypertension. A variety of other etiologies need to be considered, even in cases with coexisting hypertension. The following are the most common causes of non-hypertensive ICH.

Vascular Malformation
Vascular malformation is a relatively common cause of ICH in non-hypertensive patients, especially in younger patients. Hemorrhage from a vascular malformation is the most common cause of ICH in patients less than age 45 (49). The two clinically important types of vascular malformation related to ICH are arterioveneous malformations (AVM) and cavernous hemangiomas. Lobar ICH is the most common hemorrhage associated with both of these vascular malformations.

AVM usually presents with ICH, which occasionally may have associated subarachnoid hemorrhage. The risk of repeat hemorrhage is substantial (6% in the first year, 2% per year thereafter) (16). Neurosurgical evaluation is usually indicated. In cases believed to be surgically inaccessible, radiosurgery may be a potential treatment.

Cavernous hemangiomas comprise most of the lesion previously described as occult cerebrovascular malformations (OCVM). They may occur in multiple locations and may be familial (40). These lesions carry a substantial risk of repeat hemorrhage (4-5%/yr), and may be amenable to surgical treatment.

Aneurysm
Although usually a cause of subarachnoid hemorrhage, a ruptured saccular aneurysm may in some cases be the cause of ICH or intraventricular hemorrhage. The temporal and frontal lobes are the most common locations for ICH resulting from a ruptured saccular aneurysm.

Intracranial Tumor
Bleeding into a tumor is the cause of hemorrhage in 6-10% of patients presenting with ICH. This is most commonly seen in malignant glioma, metastatic melanoma, metastatic renal cell carcinoma, metastatic choriocarcinoma, or metastatic bronchogenic carcinoma. Clues to this cause of ICH include papilledema at presentation, multiple lesions, or disproportionate associated edema(31).

Amyloid Angiopathy
Amyloid angiopathy is a relatively common cause of ICH in elderly patients (52). Lobar ICH is the most common hemorrhage associated with amyloid angiopathy. Hemorrhage from amyloid angiopathy tends to be recurrent; a prior history of ICH in an elderly person, particularly a prior lobar ICH, raises a strong suspicion of amyloid angiopathy. There is an association of amyloid angiopathy with Alzheimer's disease (22).

Anticoagulants
ICH is patients receiving anticoagulation tends to carry a poor prognosis (50-60% mortality in one study) due to the often large size of the resultant hemorrhage (24). Hypertension, intensity of anticoagulation, and age are risk factors for development of ICH in anticoagulated patients (10,24,59). Some series have reported a relatively high percentage of anti-coagulant-related hemorrhage to be located in the cerebellum (24,39). Anticoagulation with heparin is reversible with protamine sulfate, and anticoagulation with warfarin may be reversed by administration of fresh frozen plasma and vitamin K (10).

Thrombolytics (e.g. t-PA, streptokinase)
ICH associated with thrombolytics tends to be lobar in location, and has a high mortality rate (44-66%) (15,26). The risk is relatively low in myocardial infarction treatment (0.4-1.3%), but considerably higher in acute stroke patients (48). Symptomatic ICH within 36 hours of treatment occurred in 6.4% of t-PA treated patients in the NINDS t-PA study (47). Hypertension may increase the risk of hemorrhage with thrombolytic therapy (30).

ICH associated with thrombolytics usually occurs early in he course of thrombolytic therapy, either during the infusion or with a few hours after the infusion is completed. After the infusion is stopped, the duration of thrombolytic activity remaining is four minutes for t-PA, and 15-20 minutes for streptokinase and urokinase. Replacement of fibrinogen with cryoprecipitate may partially reverse the thrombolytic effect (10).

Sympathomimetics
The sympathomimetics most often associated with ICH are cocaine and amphetamines, although phenylpropanolamine (found in decongestants and appetite suppressants) has also occasionally been implicated (9,19,25,228,29). Direct vessel injury or acute hypertension may be the mechanisms. The location tends to be lobar or involve the thalamus or putamen.

Vasculitis
Vasculitis usually is associated with ischemic infarction, but hemorrhage may also occur in both systemic and isolated central nervous system vasculitis (5).

Cerebral Venous Thrombosis
Cerebral venous thrombosis may also be present as ICH due to the associated increased venous pressure. It most often occurs during pregnancy and the post-partum period, with the use of birth control pills, and with underlying systemic disease such as cancer and systemic inflammatory conditions.

REVIEW OF MEDICAL TREATMENT

Intubation/Hyperventilation
Intubation provides airway protection, allows correction of hypoxemia, and enables the hyperventilation. Hyperventilation produces an immediate and temporary reduction in intracranial pressure (ICP), but has not been proven to affect outcome.

Corticosteriods
A randomized prospective trial has shown that corticosteroids increase complication rate and do not improve outcome in ICH (37).

Hypersmolar Therapy
Mannitol is the agent usually used for hyperosmolar therapy, and has often been utilized to treat increased intracranial pressure associated with ICH. However, no randomized controlled trials have been performed to evaluate its utility in this setting. Although mannitol reduces intracranial pressure, this effect is temporary, and upon withdrawal of mannitol, rebound intracranial hypertension may occur. Additionally, by shrinking surrounding normal brain, the possibility of promoting extension of the ICH exists. Mannitol is best used as a temporizing measure when definitive surgical treatment is anticipated.

ICP Monitoring
The role of ICP monitoring and its effect on outcome in ICH has not been defined.

Antihypertensive Therapy
Elevated blood pressure is often the causative factor for ICH; however, whether acute reduction of blood pressure is helpful or harmful is a difficult question to answer (2, 38). A recent retrospective study found that both an elevated initial blood pressure on admission (mean arterial pressure > 145 torr), and blood pressure poorly controlled after admission (mean arterial pressure > 125 torr) are associated with poor outcome. However, it is unclear whether uncontrolled as opposed to uncontrollable hypertension was related to the poor outcome.

REVIEW OF SURGICAL TREATMENT

Most patients with ICH do not require surgical management. Factors which influence the decision regarding surgical treatment include the clinical status of the patient, and the location and size of the hemorrhage. Surgical treatment is usually considered in the setting of cerebellar hemorrhage, and may also be considered in some cases of lobar hemorrhage. In addition, neurosurgical consultation should be considered in any patient with a potential underlying vascular lesion such as aneurysm, or for the treatment of hydrocephalus.

Cerebellar Hemorrhage
Surgery needs to be considered in all cases of cerebellar hemorrhage. Because of the limited space of infratentorial compartment, sudden deterioration can occur with cerebellar ICH. However, if the hematoma is small (1-2 cm), prognosis is generally good and surgery is usually not necessary. Hematomas 3 cm or larger, particularly with fourth ventricular compression, hydrocephalus, brainstem signs, or quadrigeminal cistern effacement should be considered for immediate surgical treatment in all cases, unless the patient is in deep stupor or coma (11,32,45). If the patient is comatose, mortality is greater than 80% even with surgical treatment, and surgery is not likely to be beneficial (36).

Lobar Hemorrhage
Lobar hematomas are generally the only supratentorial ICH where acute surgical treatment is considered potentially helpful. Even so, well controlled prospective studies are lacking. Patients with intermediate-sized hemorrhages (25-50cc, corresponding to a maximum diameter of 3.6 - 4.6 cm for a spherical hematoma), particularly with GCS scores of 6-8, have improved outcome with surgical treatment in some studies. this observation may be particularly true for temporal lobe hematomas. Patients with smaller hematomas improve without surgical treatment; patient with larger hematomas do poorly regardless of treatment (23, 53).

Other Locations
Although there have been occasional reports of surgical benefit in highly selected series, putaminal hemorrhages are generally not benefited from surgical treatment (4,20,25,35).

RECOMMENDATIONS

Evaluation
1. Level of consciousness and neurological status should be routinely assessed and documented for all patients with ICH. (Expert Opinion: Strong Consensus

2. CT scan should be obtained and both location and size (diameter measured in cm) of the hemorrhage should be document. Presence of mass effect and/or shift should also be noted. (Expert Opinion: Strong Consensus)

Medical Treatment
3. Any patient who is obtunded is a candidate for intubation for airway protection. The prognosis and wishes of the patient in such circumstances should be considered in making the decision regarding intubation. (Expert Opinion: Strong Consensus)

4. Corticosteroids are not recommended in the treatment of ICH. (Research Evidence: Grade B)

5. Mannitol is recommended only as a temporary measure to reduce cerebral edema in patients for whom surgery is anticipated. The recommended dosage is 0.5-1.0 gm/kg. The value of the routine use of mannitol outside this setting is uncertain. (Expert Opinion: Strong Consensus)

6. Routine treatment of elevated blood pressure is not recommended. (Expert Opinion: Strong Consensus)

7. If ICH occurs in the setting of thrombolytic, anticoagulant, or antiplatelet therapy, immediate cessation of the active agent is indicated. Reversal of thrombolytic or anticoagulant activity may also be considered. (Expert Opinion: Strong Consensus)

Surgical Treatment
8. Neurosurgical consultation should be considered:

In cases of cerebellar ICH, particularly in patients with intermediate of larger sized hematomas with evidence of mass effect and brainstem signs. By the time coma occurs, it is usually too late for surgical treatment to be beneficial. (Expert Opinion: Strong Consensus);

In cases of intermediate-sized cerebral lobar hematomas in patients with moderately impaired neurologic status. (Expert Opinion: Strong Consensus);

In patients with a potential surgical vascular lesion, in which case angiography will need to be performed. (Expert Opinion: Strong Consensus);

In some cases of ICH with intraventricular hemorrhage or hydrocephalus, where ventricular drainage may be indicated. (Expert Opinion: Strong Consensus).