Hemorrhagic stroke

Background

• Spontaneous (nontraumatic) intracerebral hemorrhage accounts for 10-15% of all strokes
• Second most common cause of stroke after ischemic stroke
• 30-day mortality: 40-50% — highest acute mortality of all stroke subtypes
• Only 20% of patients are functionally independent at 6 months

Etiology

• Hypertensive hemorrhage (most common — 55-70%):
  • Typically in basal ganglia (putamen), thalamus, pons, cerebellum
  • Chronic hypertension → lipohyalinosis of small penetrating arteries → rupture
• Cerebral amyloid angiopathy (CAA):
  • Most common cause of lobar ICH in elderly
  • Amyloid deposition in cortical/leptomeningeal vessel walls
  • Recurrent lobar hemorrhages
• Anticoagulation-related: warfarin, DOACs (hematoma expansion more common)
• Vascular malformations: AVM, cavernoma (consider in young patients without hypertension)
• Other: cocaine/amphetamine use, hemorrhagic transformation of ischemic stroke, tumors, coagulopathies, cerebral venous sinus thrombosis

Clinical Features

• Sudden onset focal neurologic deficit with headache (worse than ischemic stroke)
• Nausea, vomiting (raised ICP)
• Progressive deterioration (hematoma expansion occurs in ~30% within first 3 hours)
• Cannot reliably distinguish from ischemic stroke clinically — neuroimaging is required

Location-Specific Findings

• Putaminal (35-50%): contralateral hemiparesis, hemisensory loss, aphasia (dominant) or neglect
• Thalamic (15-20%): contralateral hemisensory loss, upgaze palsy, small pupils
• Cerebellar (5-10%): ataxia, vertigo, vomiting, headache → rapid deterioration from brainstem compression or hydrocephalus; SURGICAL EMERGENCY
• Pontine (5-10%): coma, quadriplegia, pinpoint pupils; high mortality
• Lobar (20-30%): symptoms depend on lobe; seizures more common; consider amyloid angiopathy

Differential Diagnosis

• Ischemic stroke (MUST image to distinguish)
• Subarachnoid hemorrhage
• Subdural hemorrhage / epidural hemorrhage
• Hemorrhagic tumor (metastasis, GBM)
• Cerebral venous sinus thrombosis
• Seizure with postictal deficit (Todd paralysis)
• Hypoglycemia

Evaluation

Imaging

• Non-contrast CT head (first-line — immediate): hyperdense (white) lesion
  • Detects hemorrhage with ~100% sensitivity in first hours
  • Evaluate for: hematoma size, location, midline shift, intraventricular extension, hydrocephalus
• CT angiography (CTA): identify spot sign (contrast extravasation = active bleeding, predicts hematoma expansion)
  • Also evaluates for underlying vascular malformation
• MRI/MRA: after stabilization to evaluate for underlying cause (especially if atypical location or age <50)

Labs

• Coagulation studies: PT/INR (warfarin), PTT (heparin), thrombin time (dabigatran)
• CBC with platelets
• BMP, glucose
• Type and screen
• Toxicology screen if cocaine/amphetamine use suspected

ICH Score (Prognosis)

• GCS 3-4 (+2), 5-12 (+1), 13-15 (0)
• ICH volume ≥30 cm3 (+1)
• Intraventricular hemorrhage (+1)
• Infratentorial origin (+1)
• Age ≥80 (+1)
• Score 0: ~0% 30-day mortality; Score 5: ~100% mortality
• Should NOT be used to limit care (self-fulfilling prophecy concern)

Management

Blood Pressure

• AHA/ASA Guidelines:
  • If SBP 150-220 mmHg: target SBP 140 mmHg is safe and may improve outcomes (INTERACT2 trial)
  • If SBP >220 mmHg: aggressive reduction with continuous IV infusion and frequent monitoring (target 140-160)
  • Nicardipine infusion (5-15 mg/hr) or clevidipine preferred
  • Labetalol IV as alternative
  • Avoid SBP <120 mmHg (risk of renal injury)

Anticoagulation Reversal

• Warfarin (elevated INR):
  • 4-factor PCC (Kcentra) 25-50 units/kg IV (preferred — rapid, complete reversal)
  • + Vitamin K 10 mg IV (takes hours but provides sustained reversal)
  • FFP is second-line (requires thawing, large volume, incomplete reversal)
• Dabigatran: idarucizumab (Praxbind) 5g IV (immediate reversal)
• Rivaroxaban/Apixaban: andexanet alfa (Andexxa) if available; otherwise 4-factor PCC 50 units/kg
• Heparin: protamine sulfate
• Antiplatelet agents: platelet transfusion is NOT recommended (PATCH trial showed harm)

Seizure Management

• Treat clinical seizures with benzodiazepines, then AEDs (levetiracetam preferred)
• Prophylactic AEDs are NOT routinely recommended
• Consider continuous EEG for patients with AMS out of proportion to hemorrhage

Cerebellar Hemorrhage

• Neurosurgical EMERGENCY
• Surgical evacuation for hematoma >3 cm OR evidence of brainstem compression OR hydrocephalus
• EVD (external ventricular drain) for obstructive hydrocephalus
• These patients can deteriorate rapidly to death without surgery

Increased ICP Management

• Elevate HOB to 30°
• EVD for hydrocephalus or IVH with acute hydrocephalus
• Osmotic therapy: mannitol or hypertonic saline
• Consider surgical hematoma evacuation (benefit primarily for superficial lobar hemorrhages)

Disposition

• All patients with ICH require ICU admission in a stroke center/neurosurgical center
• Neurosurgery consultation for: cerebellar hemorrhage, large hematoma with mass effect, hydrocephalus, young patient with suspected vascular malformation
• Goals of care discussion early — but avoid early withdrawal of care (ICH score is imperfect)
• Transfer to stroke center if local neurosurgical capability unavailable

See Also

• Ischemic stroke
• Subarachnoid hemorrhage
• Subdural hemorrhage
• Anticoagulation reversal
• Intracerebral hemorrhage

References

• Hemphill JC 3rd, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: AHA/ASA guideline. Stroke. 2015;46(7):2032-2060. PMID 26022637
• Anderson CS, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage (INTERACT2). N Engl J Med. 2013;368(25):2355-2365. PMID 23713578
• Baharoglu MI, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH). Lancet. 2016;387(10038):2605-2613. PMID 27178479