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12 notes available
1 Last Minute Review 2 Cerebrovascular Anatomy 3 Stroke Syndromes 4 Acute Stroke Management 5 Stroke Workup 6 Secondary Prevention 7 Intracerebral Hemorrhage 8 SAH & Aneurysms 9 SDH & EDH 10 Venous Thrombosis 11 Vascular Malformations 12 Special Vascular Topics
Clinical › Vascular

Intracerebral Hemorrhage

Intracerebral Hemorrhage

What You'll Learn

  • Hypertension is the #1 cause of spontaneous ICH; deep/infratentorial locations suggest hypertensive etiology, lobar locations suggest CAA, tumor, or vascular malformation
  • Cerebral amyloid angiopathy (CAA) diagnosis using the modified Boston criteria 2.0 — lobar microbleeds, cortical superficial siderosis, APOE associations
  • Acute blood pressure management: INTERACT2 (target <140 mmHg) vs. ATACH-2 (intensive lowering not superior, may cause renal harm)
  • Reversal of anticoagulation: warfarin → 4-factor PCC + vitamin K; dabigatran → idarucizumab; factor Xa inhibitors → andexanet alfa or 4F-PCC
  • ICH Score components and 30-day mortality prediction; awareness of self-fulfilling prophecy / early care limitation bias
  • CTA spot sign predicts hematoma expansion; hematoma expansion occurs in ~30% within first hours and is the strongest modifiable predictor of poor outcome
  • Surgical trials: STICH/STICH II (no general benefit for supratentorial ICH), MISTIE III, cerebellar ICH >3 cm → surgical evacuation
  • CLEAR III trial for intraventricular hemorrhage; EVD management for obstructive hydrocephalus
HighYield Pearls
  • Location predicts etiology: putamen / thalamus / pons / cerebellum / caudate → hypertensive (deep penetrator rupture); lobar in elderly → CAA (Boston 2.0); lobar in young → AVM / cavernoma / hemorrhagic tumor.
  • BP target (SBP 150–220, mild-moderate ICH): smoothly lower to ~140 and maintain 130–150; avoid SBP <130. INTERACT-2 supported SBP <140 (safe). ATACH-2 tested intensive SBP 110–139 vs 140–179 and showed no death/disability benefit with increased renal adverse events. Use IV nicardipine / clevidipine / labetalol; avoid hypotension (MAP ≥85).
  • Anticoagulation reversal is emergent: warfarin → 4F-PCC (Kcentra) + vitamin K 10 mg IV (faster than FFP); dabigatran → idarucizumab (Praxbind); apixaban/rivaroxaban → andexanet alfa (or 4F-PCC if unavailable); heparin → protamine.
  • tPA / TNK-related ICH → stop infusion → emergent CT + CBC/PT/PTT/INR/fibrinogen/type & cross → cryoprecipitate (often 10 U initial) to maintain fibrinogen ≥150–200 ± TXA or aminocaproic acid; reserve platelets for thrombocytopenia or specific antiplatelet/procedural scenarios.
  • PATCH trial: platelet transfusion for spontaneous ICH on antiplatelet is HARMFUL — do NOT give routinely; reserve for surgical patients or severe thrombocytopenia.
  • Cerebellar ICH >3 cm or with brainstem compression / hydrocephalus / clinical deterioration → emergent suboccipital decompression ± EVD (do NOT just place EVD alone — risk of upward herniation).
  • STICH / STICH II: no benefit for routine supratentorial ICH evacuation; MISTIE III minimally-invasive + tPA was neutral on primary outcome; ENRICH (lobar, early minimally invasive) showed functional benefit.
  • CTA spot sign → contrast extravasation predicting hematoma expansion; expansion in ~30% within first 24 h is the strongest modifiable predictor of poor outcome.
  • ICH Score (GCS, age ≥80, volume ≥30 mL, infratentorial, IVH) → 30-day mortality; beware self-fulfilling prophecy of early DNR / withdrawal.
  • CLEAR III: intraventricular tPA via EVD for IVH → modest mortality benefit, no functional benefit; AED only if seizure, not prophylactic; DVT prophylaxis 24–48 h after bleed stable; CAA → avoid anticoagulation, consider LAA closure if AF; caution with lecanemab/donanemab (ARIA-H risk).
🔍 Quick ReferenceLocation / etiology · Imaging / scoring · BP / reversal / surgery
Location → etiology
  • Putamen / external capsule → hypertensive ICH (lenticulostriate rupture — most common location)
  • Thalamus → hypertensive (thalamoperforator); often with IVH and hydrocephalus
  • Pons → hypertensive (pontine perforators); pinpoint pupils, locked-in, high mortality
  • Cerebellum (dentate) → hypertensive; surgical lesion if >3 cm or brainstem compression
  • Lobar ICH in elderly + cortical superficial siderosis + microbleeds → CAA (Boston 2.0)
  • Lobar ICH in young, AVM nidus / flow voids → arteriovenous malformation
  • Hemorrhagic mets — “MR CT”: Melanoma, RCC, Choriocarcinoma, Thyroid (± lung, breast)
  • Young patient + hypertensive surge + lobar ICH → cocaine / amphetamine / sympathomimetic
  • Bilateral parasagittal hemorrhage near sinus → cerebral venous sinus thrombosis
  • Distal mycotic aneurysm rupture → infective endocarditis
Imaging / scoring
  • Spot sign (CTA contrast extravasation) → predicts hematoma expansion
  • Swirl sign (hypodensity within hyperdense hematoma on NCCT) → active bleeding / expansion
  • Blend sign (hyperdense + hypodense regions, well-defined margin) → expansion
  • Black hole sign (encapsulated hypodensity within hematoma) → expansion
  • Island sign (≥3 scattered small hematomas around main clot) → expansion
  • ICH Score: GCS + age ≥80 + volume ≥30 mL + infratentorial + IVH → 30-day mortality
  • ABC/2 rule → quick bedside hematoma volume estimate
  • Cortical superficial siderosis + lobar microbleeds on SWI/GRE → CAA (Boston 2.0)
  • FUNC score → 90-day functional independence prediction
BP / anticoag reversal / surgery
  • Target SBP ~140, maintain 130–150 for mild-moderate ICH (SBP 150–220); INTERACT-2 supported <140 as safe
  • ATACH-2: intensive SBP 110–139 vs 140–179 → no death/disability benefit, more renal adverse events; avoid SBP <130
  • IV nicardipine / clevidipine / labetalol drip → preferred agents; avoid nitroprusside (ICP ↑)
  • 4F-PCC (Kcentra) + vitamin K 10 mg IV → warfarin reversal (faster than FFP)
  • Idarucizumab (Praxbind) → dabigatran reversal
  • Andexanet alfa (or 4F-PCC) → apixaban / rivaroxaban reversal
  • Protamine sulfate → heparin reversal
  • Cryoprecipitate 10 U ± TXA / aminocaproic acid → tPA/TNK-related ICH (platelets only if thrombocytopenia or specific antiplatelet/procedural indication)
  • PATCH trial — platelets HARMFUL → do not transfuse for spontaneous ICH on antiplatelet
  • Suboccipital craniectomy ± EVD → cerebellar ICH >3 cm or brainstem compression
  • STICH / STICH II neutral → no routine supratentorial evacuation
  • ENRICH (minimally invasive early lobar) → functional benefit
  • CLEAR III intraventricular tPA → mortality benefit, no functional benefit in large IVH
  • LAA closure (Watchman) → AF + prior ICH / CAA when anticoagulation contraindicated
Epidemiology & Risk Factors

Epidemiology

  • ICH accounts for 10–15% of all strokes but carries the highest mortality (~40% at 30 days)
  • Incidence: ~25 per 100,000 person-years in the U.S.; higher in Asian and Black populations
  • Median age of onset: 60–70 years
  • ICH is the most common type of hemorrhagic stroke (more common than SAH)
  • Only ~20% of ICH patients are functionally independent at 6 months

Risk Factors

Modifiable

  • Hypertension — #1 risk factor overall (accounts for 60–70% of spontaneous ICH); chronic HTN → lipohyalinosis of small penetrating arteries
  • Anticoagulation: Warfarin-associated ICH carries ~50% mortality; DOACs have lower ICH risk than warfarin
  • Antiplatelet agents: Modestly increase ICH risk, especially dual antiplatelet therapy
  • Heavy alcohol use: >2 drinks/day increases ICH risk 2–4 fold
  • Cocaine / amphetamines / sympathomimetics: Acute hypertensive surge → ICH; often in younger patients; consider in any young patient with ICH
  • Smoking: Independent risk factor; synergistic with HTN

Non-Modifiable / Structural

  • Cerebral amyloid angiopathy (CAA): Leading cause of lobar ICH in elderly; recurrent lobar hemorrhages
  • Vascular malformations: AVMs, cavernous malformations, dural AVFs — especially in young patients with lobar ICH
  • Brain tumors: Primary (GBM, oligodendroglioma) and metastatic (melanoma, RCC, choriocarcinoma, thyroid) — hemorrhagic metastases
  • Coagulopathies: Thrombocytopenia, DIC, hemophilia, liver disease
  • Cerebral venous thrombosis: Venous infarction with secondary hemorrhagic conversion — often bilateral, near sinuses
  • Moyamoya disease: ICH from fragile collateral vessels in young Asian patients
  • Vasculitis / mycotic aneurysm: Infective endocarditis → septic emboli → mycotic aneurysm rupture
💎 Board Pearl

Hemorrhagic brain metastases — “MR CT” mnemonic: Melanoma, Renal cell carcinoma, Choriocarcinoma, Thyroid. These tumors have a high propensity to bleed. Any lobar ICH in a patient with known cancer should raise suspicion for hemorrhagic metastasis.

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