11/16/13 Intracranial Hemorrhage

emedicine.medscape.com/article/1163977-overview#a0104 1/7
Intracranial Hemorrhage
Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more...

Updated: Jan 23, 2013
Background
Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may occur within brain
parenchyma or the surrounding meningeal spaces. Hemorrhage within the meninges or the associated potential
spaces, including epidural hematoma, subdural hematoma, and subarachnoid hemorrhage, is covered in detail in
other articles. Intracerebral hemorrhage (ICH) and extension of parenchymal bleeding into the ventricles (ie,
intraventricular hemorrhage [IVH]) are detailed here.
Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders.
Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid
hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue,
leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of
intracranial pressure (ICP) and potentially fatal herniation syndromes.
Pathophysiology
Nontraumatic intracerebral hemorrhage most commonly results from hypertensive damage to blood vessel walls
(eg, hypertension, eclampsia, drug abuse), but it also may be due to autoregulatory dysfunction with excessive
cerebral blood flow (eg, reperfusion injury, hemorrhagic transformation, cold exposure), rupture of an aneurysm or
arteriovenous malformation (AVM), arteriopathy (eg, cerebral amyloid angiopathy, moyamoya), altered hemostasis
(eg, thrombolysis, anticoagulation, bleeding diathesis), hemorrhagic necrosis (eg, tumor, infection), or venous
outflow obstruction (eg, cerebral venous thrombosis). Nonpenetrating and penetrating cranial trauma are also
common causes of intracerebral hemorrhage.
Chronic hypertension produces a small vessel vasculopathy characterized by lipohyalinosis, fibrinoid necrosis,
and development of Charcot-Bouchard aneurysms, affecting penetrating arteries throughout the brain including
lenticulostriates, thalamoperforators, paramedian branches of the basilar artery, superior cerebellar arteries, and
anterior inferior cerebellar arteries.
Predilection sites for intracerebral hemorrhage include the basal ganglia (40-50%), lobar regions (20-50%),
thalamus (10-15%), pons (5-12%), cerebellum (5-10%), and other brainstem sites (1-5%).
Intraventricular hemorrhage occurs in one third of intracerebral hemorrhage cases from extension of thalamic
ganglionic bleeding into the ventricular space. Isolated intraventricular hemorrhage frequently arise from
subependymal structures including the germinal matrix, AVMs, and cavernous angiomas.
Epidemiology
Frequency
United States
Each year, intracerebral hemorrhage affects approximately 12-15 per 100,000 individuals, including 350
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hypertensive hemorrhages per 100,000 elderly individuals. The overall incidence of intracerebral hemorrhage has
declined since the 1950s.
International
Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the world.
Mortality/Morbidity
Annually, more than 20,000 individuals in the United States die of intracerebral hemorrhage. Intracerebral
hemorrhage has a 30-day mortality rate of 44%. Pontine or other brainstem intracerebral hemorrhage has a
mortality rate of 75% at 24 hours. Hallevi et al reviewed the charts and CT scans of patients with intraventricular
hemorrhage (IVH) to determine if the extension of the hemorrhage could be measured. Clinical outcome was
determined by the modified Rankin Scale (mRS). IVH was also classified with an IVH score. The IVH score
allowed rapid estimate of IVH volume by the practitioner and increased predictability for outcome.
[1]
Race
Intracerebral hemorrhage has a higher incidence among populations with a higher frequency of hypertension,
including African Americans. A higher incidence of intracerebral hemorrhage has been noted in Chinese,
Japanese, and other Asian populations, possibly due to environmental factors (eg, a diet rich in fish oils) and/or
genetic factors.
Sex
Intracerebral hemorrhage has a slight male predominance, though study results have been conflicting.
Cerebral amyloid angiopathy may be more common among women.
Phenylpropanolamine use has been associated with intracerebral hemorrhage in young women.
[2]
Age
Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade
until age 80 years. The relative risk of intracerebral hemorrhage is greater than 7 in individuals older than 70 years.
In individuals younger than 45 years, lobar hemorrhage is the most common site of and frequently is associated
with AVMs.
Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in premature infants.

Contributor Information and Disclosures
Author
David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program,
University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging
Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke
Center
David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology,
American Heart Association, American Medical Association, American Society of Neuroimaging, American
Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.
Specialty Editor Board
Jeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University of
California, Los Angeles, David Geffen School of Medicine
Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of
Neurology, American Heart Association, American Neurological Association, and National Stroke Association
11/16/13 Intracranial Hemorrhage
emedicine.medscape.com/article/1163977-overview#a0104 3/7
Disclosure: University of California The University of California Regents receive funds for consulting services on
clinical trial design provided to Telecris, Ev3, and CoAxia. Consulting
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice
Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke
Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff,
Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Neurology, American Heart Association, American Medical Association, American Neurological
Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and
Tennessee Medical Association
Disclosure: Nothing to disclose.
Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology
and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology,
American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy
Society, and American Medical Association
Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting;
Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting;
Sleepmed/DigiTrace Honoraria Speaking, consulting; Sunovion Consulting fee None
Chief Editor
Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science
University School of Medicine; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and
American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel
membership; Concentric Medical Consulting fee Review panel membership
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