Brain (CNS)
Hemorrhagic Stroke (ICH)
출혈성뇌졸중
Intraparenchymal hemorrhage causing acute neurologic deficit and raised ICP
- How common
- 15-20% of strokes
- Typical age
- Ages 50-70
What is it?
Chronic hypertensive lipohyalinosis of perforators (Charcot-Bouchard aneurysms) or amyloid deposition → rupture → hematoma plus peri-hematomal edema.
Commonly affected: Basal ganglia/thalamus (HTN), lobar (CAA), cerebellum/brainstem
How it develops
- Vessel wall weakeningHypertensive microaneurysms or cerebral amyloid angiopathy
- Rupture and hematomaDeep nuclei, brainstem, cerebellum, lobar hemorrhage
- Hematoma expansionUp to 30% expand within first 6 hours
- Raised ICP/herniationEdema and mass effect cause herniation
Symptoms
- Sudden severe headacheWorst headache of life
- Focal deficitsVary by hemorrhage location
- Decreased consciousness/comaDecreased GCS, herniation risk
- VomitingSign of raised ICP
- SeizuresCommon in lobar hemorrhage
How it is examined
- Glasgow Coma ScaleEye/Verbal/Motor (3-15)
- Pupillary/brainstem reflexesAssess for herniation signs
- ICH scoreGCS, age, location, volume, IVH
Imaging
Non-contrast head CT first - acute blood is hyperdense.
- Hyperdense hematoma
- Peri-hematomal edema
- Midline shift
CTA for spot sign (predicts expansion), MRI GRE/SWI shows microbleeds.
- CTA spot sign
- Cortical microbleeds (CAA)
- Amyloid distribution
Non-surgical care
- BP loweringTarget SBP 140 mmHg (INTERACT-2/ATACH-II)
- Anticoagulation reversalVit K + 4F-PCC for warfarin; idarucizumab (dabigatran); andexanet (FXa)
- ICP managementHead-up 30°, mannitol 1 g/kg or 3% saline
- Seizure mgmtLevetiracetam for clinical seizures
- Neuro ICU monitoringHourly neuro checks, glucose/temp control
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Cerebellar ICH >3 cm, GCS decline, hydrocephalus, accessible lobar ICH
Procedures that may be discussed
- Suboccipital craniectomy + clot evacuation
- EVD for hydrocephalus
- Minimally invasive evacuation (MISTIE-III)
- Decompressive craniectomy
Outlook
30-day mortality 30-40%. ICH score ≥4 has >90% mortality. Rehabilitation drives recovery.