Intracerebral haemorrhage - Cerebrovascular disease

Intracerebral haemorrhage

Definition

Spontaneous haemorrhage may occur within in the basal ganglia, internal capsule, cerebellum or pons presenting as a stroke.

Incidence

Accounts for 15% of strokes.

Age

Occurs most commonly in the elderly.

Aetiology/pathophysiology

Prolonged uncontrolled hypertension is the most common cause. Pseudoaneurysms form on fine perforating arteries, these have a tendency to rupture leading to haemorrhage.

Arteriovenous malformations may haemorrhage especially in younger patients.

Cerebral hemisphere haemorrhages may be caused by cerebral amyloid (accounting for 10% of haemorrhages in people over 70 years of age).

Other causes include bleeding into a tumour, disorders of coagulation and rarely, vasculitis.

Intracranial venous thrombosis may be complicated by intracerebral haemorrhage.

Clinical features

Clinical signs are unreliable in distinguishing ischaemic stroke from a haemorrhagic stroke, hence this is a diagnosis made following a CT brain scan. Headache and coma are more common in intracerebral haemorrhage.

Macroscopy

Blood clot which causes compression to the surrounding brain. If the patient survives the haematoma is removed by phagocytosis, and replaced by gliosis.

Management

Resuscitate as necessary with management of the airway, breathing and circulation.

Reverse any clotting deficiency and avoid aspirin.

Hypertension needs to be treated cautiously, in the early stages, to prevent hypoperfusion.

Neurosurgery is rarely indicated, but is often required in cerebellar bleeds which may cause obstructive hydrocephalus.

Rehabilitation, ideally on a stroke unit, includes physiotherapy, speech therapy, and occupational therapy to gain maximal resolution of the neurological deficits. Any risk factors present, particularly hypertension, should be managed to help prevent recurrence.