Spontaneous intracerebral hemorrhage: a review

Abstract

<jats:p>Spontaneous intracerebral hemorrhage (SICH) is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10 to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage. Common causes include hypertension, amyloid angiopathy, coagulopathy, vascular anomalies, tumors, and various drugs. Hypertension, however, remains the single greatest modifiable risk factor for SICH. Computerized tomography scanning is the initial diagnostic modality of choice in SICH, and angiography should be considered in all cases except those involving older patients with preexisting hypertension in thalamic, putaminal, or cerebellar hemorrhage. Medical management includes venous thrombosis prophylaxis, gastric cytoprotection, and aggressive rehabilitation. Anticonvulsant agents should be prescribed in supratentorial SICH, whereas the management of hypertension is controversial.</jats:p> <jats:p>To date, nine prospective randomized controlled studies have been conducted to compare surgical and medical management of SICH. Although definitive evidence favoring surgical intervention is lacking, there is good theoretical rationale for early surgical intervention. Surgery should be considered in patients with moderate to large lobar or basal ganglia hemorrhages and those suffering progressive neurological deterioration. Elderly patients in whom the Glasgow Coma Scale score is less than 5, those with brainstem hemorrhages, and those with small hemorrhages do not typically benefit from surgery. Patients with cerebellar hemorrhages larger than 3 cm, those with brainstem compression and hydrocephalus, or those exhibiting neurological deterioration should undergo surgical evacuation of the clot. It is hoped that the forthcoming results of the International Surgical Trial in IntraCerebral Hemorrhage will help formulate evidence-based recommendations regarding the role of surgery in SICH.</jats:p>

Discrimination of Tumorous Intracerebral Hemorrhage from Benign Causes Using CT Densitometry

“…We propose that histogram analysis is a useful tool for detecting hidden solid tumor lesions within acute ICH, which might be helpful in establishing appropriate imaging follow-up and avoiding delays in long-term management of tumorous ICHs. Vascular malformation, another common cause of secondary ICH, 6,7 showed relatively higher attenuation, similar to that of primary ICH, and thus could be discriminated from tumorous ICH. One explanation for this result is that rupture of abnormal vessels is the main pathophysiology of acute bleeding.…”

“…1 Tumors account for 10% of all spontaneous ICH cases. 6,7 Earlier discrimination of tumorous etiology from nontumorous causes of acute ICH might be helpful to determine appropriate imaging follow-up and avoid delays in long-term management of tumorous ICH, though acute management would not differ. Nonenhanced CT (NECT) is the standard investigation tool for acute ICH.…”

Meta-analyses of intracerebral hematoma treatment

“…Criterias on treatment decision include; patient's age, hematoma volume, location and deepness from the surface, Glasgow coma scale (GCS), pathologies underlying hematoma (aneurysm, AVM, trauma etc. ), time duration between hemorrhage and diagnosis, severe coagulopathy or presence of underlying serious medical disease, progression on neurological deficits or conscious, development of obstructive hydrocephaly, and compression of brain stem (3,8,9). However, The STICH (surgical treatment for intracerebral haemorrhage) study showed no overall benefit from early surgery when compared with initial conservative treatment (25).…”

“…If there is an underlying pathology of the hematoma, intervention should also be performed to that lesion during the surgery (3,8,9).…”

“…Fewel et al (9) suggested that surgery should be considered in patients with moderate to large lobar or basal ganglia hemorrhages and those suffering progressive neurological deterioration, Proust et al (25) suggested supratentorial craniotomy for patients with GCS>8, HC volume of 10-40ml, lobar or for hematomas located at about 1cm to cortical surface.…”