Acute intracerebral haemorrhage: diagnosis and management

Since your doctor and hospital don't know what to do when this occurs they should immediately get research going to solve that problem. YOUR RESPONSIBILITY  is to ensure your hospital initiates that research. Or don't you want your children and grandchildren to have better care?

Acute intracerebral haemorrhage: diagnosis and management

1. http://orcid.org/0000-0001-8457-1748Iain J McGurgan1,
2. Wendy C Ziai2,
3. David J Werring3,
4. Rustam Al-Shahi Salman4,
5. Adrian R Parry-Jones5

1. Correspondence to Adrian R Parry-Jones, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK; adrian.parry-jones@manchester.ac.uk

Abstract

Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome.(So no protocols for anything here. Good to know you might want to try to have a more treatable stroke to match your doctor's skills.) Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

http://dx.doi.org/10.1136/practneurol-2020-002763

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INTRODUCTION

Spontaneous intracerebral haemorrhage (ICH) refers to non-traumatic bleeding in the brain parenchyma and is the deadliest form of stroke. The high 1-month case-fatality rate of ~40% and poor long-term outcome make it a major contributor to global morbidity and mortality.^{1 2} Although ICH accounts for a minority of stroke worldwide (10–30%), it is associated with a greater burden of disability-adjusted life years than ischaemic stroke, given its high incidence in low- and middle-income countries.³ Despite dramatic drops in ischaemic stroke mortality rates,³ there has been limited improvement in case fatality from ICH in the last few decades^{2 4 5} and most survivors are left with severe disability.^{2 6 7}

ICH is not a single entity; 85% of cases are due to cerebral small vessel disease, predominantly deep perforator arteriopathy (also termed hypertensive arteriopathy or arteriosclerosis) and cerebral amyloid angiopathy, while the remainder results from a macrovascular (eg, arteriovenous malformation, cavernoma, aneurysm and venous thrombosis) or neoplastic cause. Vascular malformations are the most common cause of ICH in young adults, accounting for up to one-third of cases.⁸ The term ‘primary’ ICH is often applied to cases caused by cerebral small vessel disease, but it discourages adequate investigation and accurate classification and is not recommended. Deep haemorrhages account for about two-thirds of cases, occur in the internal capsule, basal ganglia or brainstem, and more likely result from deep perforator arteriopathy. About 5–10% of ICH occurs in the cerebellum. The remainder is lobar haemorrhage located in cortico-subcortical areas, often near or reaching the cerebral convexities, of which ~40% are due to arteriosclerosis alone, ~40% to arteriosclerosis and amyloid angiopathy and the remaining ~20% to amyloid angiopathy alone.⁹

There are no medical treatments for acute ICH that have been definitively proven in primary outcome analyses of randomised clinical trials. Patients with ICH are frequently referred for surgery, but the roles of various surgical methods and timing of surgery remain controversial. In this article, we outline a practical approach to the diagnosis and management of acute ICH.