INTRACEREBRAL HEMORRHAGE
Diagnosis of intracerebral hemorrhage
Created 27/04/2021, last revision 29/04/2023
- in patients presenting with stroke-like symptoms, rapid neuroimaging with CT or MRI is recommended to confirm the diagnosis of spontaneous ICH
- detection of intracerebral bleeding is easy on imaging methods, and the diagnostic evaluation is focused on the determination of etiology
Physical Examination and focused history
- focused personal history (see tab below)
- quick physical examination → Early management of patients with suspected stroke
- vital signs – assessment of airway, breathing, circulation
- a general physical examination focusing on the head, heart, lungs, abdomen, and extremities
- a focused neurological examination + NIHSS
- assess GCS in patients with impaired LOC
- time of symptoms onset (or time patient was last seen normal)
- symptoms
- headache
- Thunderclap: Aneurysm, RCVS, some instances of CVST
- Slower onset: Mass lesion, some instances of CVST, ischemic stroke with hemorrhagic transformation
- Focal neurologic deficits
- Seizures
- Decreased level of consciousness
- headache
- vascular risk factors Ischemic stroke
- prior ICH or SAH
- hypertension
- hyperlipidemia
- diabetes
- metabolic syndrome
- imaging biomarkers (e.g., cerebral microbleeds)
- medications
- anticoagulant drugs
- thrombolytic drugs
- antiplatelet agents
- NSAIDs
- vasoconstrictive agents (associated with RCVS): triptans, SSRIs, decongestants, stimulants, phentermine, sympathomimetic drugs
- antihypertensives (as a marker of chronic hypertension)
- estrogen-containing oral contraceptives (risk of CVST)
- cognitive impairment or dementia (possible amyloid angiopathy)
- substance use
- smoking
- alcohol use
- marijuana (associated with RCVS)
- sympathomimetic drugs (amphetamines, methamphetamines, cocaine)
- liver disease, uremia, malignancy, and hematologic disorders (→ secondary coagulopathy)
Computed tomography (CT)
Non-contrast CT scan (NCCT)
- baseline examination objectives:
- detect and localize the hematoma
- assess its type, volume, probable etiology, risk of complications
- assess the prognosis (→ ICH scales)
- fresh blood is hyperdense on NCCT
- increased density is caused by the high hemoglobin content of retracted clot or sedimented blood
- the density of the hematoma in the acute stage is typically around 70-80HU; if the lesion has a density > 100-120HU, probable calcification, foreign body, etc. are depicted
- resorption of the hematoma occurs within days to weeks; it is accompanied by a decrease in its density
- within 1-6 weeks, hematoma becomes isodense
- in the chronic stage, we usually find a hypodense pseudocyst with atrophy of the surrounding brain tissue at the site of the absorbed hematoma (it cannot be distinguished from old ischemia)
- increased density is caused by the high hemoglobin content of retracted clot or sedimented blood
- vasogenic edema gradually appears around the subacute hematoma as a hypodense area
- type and localization of bleeding:
- typical “hypertonic” bleeding
- putaminal and thalamic, internal capsule (lenticulostriate artery)
- brainstem, cerebellum
- concomitant hypertension + age > 55 years almost rule out other etiologies
- putaminal and thalamic, internal capsule (lenticulostriate artery)
- atypical bleeding
- lobar hematomas
- primary intraventricular hemorrhage (IVH) – exclude AVM or small aneurysm in the ventricular wall or SAH from ACoA with perforation of the terminal lamina and blood propagation into the third ventricle
- age < 50 years in the absence of hypertension despite localization
- → search for the cause (CTA/MRI+MRA/DSA)
- lobar hematomas
- typical “hypertonic” bleeding
- there are several NCCT predictors of hematoma expansion and unfavorable outcome in acute ICH
- Satellite sign, Island sign – subtle hemorrhages near the main hematoma
[Li, 2017] [Shimoda, 2017] - Blend sign
[Li, 2017] - Black Hole sign
[Li, 2016]
- Satellite sign, Island sign – subtle hemorrhages near the main hematoma
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CT angiography (CTA)
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Magnetic resonance imaging (MRI)
- MRI of the brain is highly sensitive for detecting intracerebral hemorrhage
- hemorrhage appearance depends on the stage of hemoglobin breakdown (see table below)
- oxy-Hb is weakly diamagnetic, deoxy-Hb has 4 unpaired electrons per iron atom and is strongly paramagnetic
- gradient recalled echo sequence (GRE) can detect early bleeding with similar sensitivity to NCCT ⇒ MRI can be used as an initial imaging method in stroke program (Kidwell, 2004) → see here
- hyperacute hematoma:
- T1 isointense
- T2/FLAIR – isointense or mildly hyperintense
- GRE hypointense (initially only hypointense rim + core of heterogenous signal intensity (due to the diamagnetic oxyhemoglobin)
- DWI hyperintense, ADC hypointense
- hyperacute hematoma:
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Digital subtraction angiography (DSA)
- indicated in search for the source of bleeding (consider patients’ age, clinical condition, comorbidities, prognosis, the localization and extent of bleeding)
- DSA is often replaced by CTA/MRA, which can be performed quickly and without significant risk as part of the initial diagnostic evaluation
- DSA should be performed if CTA/MRA suggests a macrovascular cause of bleeding (AHA/ASA 2022 1/C-LD)
- DSA confirms the diagnosis and provides additional information about the main tributaries, presence, type, and extent of the nidus, type of flow (high or low flow), venous drainage, and other pathologies (stenosis of a draining vein, intranidal or perinidal aneurysm, etc.)
- DSA is performed when CTA/MRA is negative or unclear, and there is a reasonable suspicion of a bleeding source
- age < 50 years, with the absence of hypertension
- atypical localization or appearance of the hematoma
- typical localization without a history of hypertension
- isolated intraventricular hemorrhage (AHA/ASA 2022 1/BNR)
- in patients with spontaneous ICH and a negative DSA and no clear microvascular diagnosis or other structural lesions, it may be reasonable to perform a repeat DSA 3-6 months after ICH to identify a previously obscured vascular lesion
Other examinations and tests
Blood tests
- complete blood count (check platelets)
- admission anemia is associated with hemorrhagic expansion and poor outcomes
- thrombocytopenia is associated with increased mortality
- coagulation tests (to exclude anticoagulant-related hemorrhage and coagulopathy from other causes)
- APTT, Quick, INR, TT, fibrinogen (especially after thrombolysis)
- ECT and Hemoclot (dabigatran) → see here
- specific anti-Xa (xabans) → see here
- glucose
- admission hyperglycemia is associated with unfavorable short- and long-term outcome
- urea nitrogen, osmolality
- liver tests (coagulopathy secondary to liver failure)
- ionogram including Ca2+, Mg2+
- creatinine/estimated glomerular filtration rate (GFR)
- renal failure on admission also is associated with poor functional outcome
- possible altered clearance of DOACs
- D-dimers
- cardiac enzymes + troponin
- inflammatory markers (ESR, CRP) – infective endocarditis?
- urine toxicology screen (sympathomimetic drugs are associated with ICH)
- pregnancy test in a woman of childbearing age (exclude peripartum angiopathy, eclampsia, HELLP syndrome, and cerebral sinus thrombosis)
Others
- 12-lead ECG on admission, followed by continuous ECG monitoring
- pulse oximetry
- blood pressure monitoring (invasive/noninvasive)
- chest x-ray
