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Definition
• Defined as abrupt onset of severe headache,
altered level of consciousness, or focal
neurological deficit associated with:
– a focal collection of blood within the brain parenchyma
on neuroimaging or at autopsy
National Institute of Neurological Disorders and Stroke. Classification of cerebrovascular diseases III. Stroke
1990; 21: 637–676.
Epidemiology
• The incidence of ICH is defined as the
percentage of a population experiencing a first
ICH in a given time period.
Kissela B, Schneider A, Kleindorfer D, et al. Stroke in a biracial population: the excess burden of stroke among
blacks. Stroke 2004; 35: 426–431
Rothwell PM, Coull AJ, Giles MF, et al. for the Oxford Vascular Study. Change in stroke incidence, mortality, case-
fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004; 363:
1925–1933
Proportional Distribution of ICH in
Different Studies
Total Lobar Deep Brainstem Cerebellum
ICH % % % %
Greater 1038 359 (35) 512 (49) 65 (6) 102 (10)
Cincinnati
Izumo City, 350 53 (15) 242 (69) 30 (9) 25 (7)
Japan
Southern 341 176 (52) 121 (36) 15 (4) 29 (9)
Sweden
Jyvaskyla
region, 158 53 (34) 77 (49) 11 (7) 17 (11)
Finland
Dijon, 87 16 (18) 58 (67) 5 (6) 8 (9)
France
Perth, 60 19 (32) 31 (52) 4 (7) 6 (10)
Australia
Flaherty ML, Woo D, Haverbusch M, et al. Racial variations in location and risk of intracerebral hemorrhage. Stroke
2005; 36: 934–937
Nilsson OG, Lindgren A, Stahl N, Brandt L, Saveland H. Incidence of intracerebral and subarachnoid haemorrhage in
southern Sweden. J Neurol Neurosurg Psychiatry 2000; 69: 601–607
Risk factors for intracerebral hemorrhage
• Age and race
• Hypertension
• Cerebral amyloid angiopathy
• Apolipoprotein E
• Aneurysms and vascular malformations
• Anticoagulant- and thrombolytic associated ICH
• Antiplatelet drugs
• Cerebral microbleeds
• Prior cerebral infarction
• Hypocholesterolemia
• Heavy alcohol use
• Tobacco use
• Diabetes
• Heritability
Clinical presentation of symptoms by subtype
of stroke
Mohr JP, Caplan LR, Melski JW, et al. The Harvard Cooperative Stroke Registry: a prospective registry.
Neurology 1978; 28: 754–762
Mortality of ICH based on volume and
location of hematoma
Pontine
44% 43% 100% N/A
(n=9)
Cerebellum 64% 57% 75% N/A
(n=11)
N/A=not applicable
Broderick J, Brott T, Duldner J, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use
predictor of 30-day mortality. Stroke 1993; 24: 987–993.
Annual age-specific, race-stratified incidence
rates of ICH*
200
180 Whites
160 Blacks
140
Incidence rate / 100 000
120
100
80
60
40
20
0
20-34 35-54 55-74 75-84 85+
Age
3- >180mmHg
>130mmHg No
or if
1-Consider aggressive BP reduction with continuous IV infusion
2-Consider monitoring ICP and reducing BP using intermittent or continuous IV
medications to keep CPP >60–80mmHg
3-Consider a modest reduction of BP (e.g., MAP of 110mmHg or target BP of
160/90 mmHg) using intermittent or continuous IV medications to control BP.
*Recommendations for the management of intracranial haemorrhage – part I: spontaneous intracerebral haemorrhage.
The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee.
Cerebrovasc Dis 2006; 22(4): 294–316.
• Common sites of a cerebral hemorrhage are:
Basal ganglia (50%)
Thalamus (10-15%)
Pons (5-12%)
Cerebellum (1-5%)