Intracerebral Hemorrhage (ICH) 

1️⃣ Definition

Intracerebral Hemorrhage (ICH) is a type of hemorrhagic stroke caused by spontaneous bleeding into the brain parenchyma, leading to mass effect, raised ICP, inflammation, and secondary neuronal injury.

It accounts for:

• 10–15% of all strokes
• But causes disproportionately high mortality (35–50%)

2️⃣ Classification

A. By Etiology

B. By Location

🔹 Deep ICH (Hypertensive)

• Basal ganglia (putamen) – most common
• Thalamus
• Pons
• Cerebellum

🔹 Lobar ICH (Amyloid / tumor related)

• Frontal
• Parietal
• Temporal
• Occipital

3️⃣ Etiology 

 1. Chronic Hypertension

• Lipohyalinosis
• Charcot-Bouchard microaneurysms
• Deep hemorrhage

2. Cerebral Amyloid Angiopathy (CAA)

• Elderly
• Recurrent lobar bleeds
• No hypertension

 3. Anticoagulation

• Warfarin
• DOACs
• Thrombolysis

 4. Vascular Malformations

• AVM
• Cavernoma

 5. Others

• Brain tumor (glioblastoma, metastasis)
• Cocaine
• Coagulopathy
• Vasculitis

4️⃣ Pathophysiology 

Primary Injury

• Mass effect
• Hematoma expansion (first 6–24 hrs)

Secondary Injury

• Perihematomal edema
• Thrombin toxicity
• Excitotoxicity
• Blood–brain barrier disruption
• Inflammation cascade

Hematoma expansion occurs in ~30–40% patients within 24 hrs

5️⃣ Clinical Presentation

Classic features:

• Sudden headache
• Vomiting
• Decreased GCS
• Focal deficit

6️⃣ Diagnosis

 1. Non-Contrast CT Brain – GOLD STANDARD (Initial)

• Hyperdense area
• Mass effect
• Midline shift
• Intraventricular extension

 2. CTA

• Detects spot sign (predicts expansion)

 3. MRI

• Better for CAA
• Underlying tumor

7️⃣ ICH Score 

Mortality increases with higher score.

CRITICAL CARE MANAGEMENT

1️⃣ Initial Stabilization (ABC)

• Airway protection (GCS ≤8)
• Maintain SpO₂ >94%
• Avoid hypercapnia
• Maintain normoglycemia
• Control temperature

2️⃣ Blood Pressure Management 

According to 2022 AHA/ASA Guidelines

• If SBP 150–220 mmHg
  → Target SBP 140 mmHg

Avoid:

• SBP <130 mmHg

Preferred IV agents:

• Nicardipine infusion
• Labetalol
• Clevidipine

Avoid nitroprusside (↑ ICP)

3️⃣ Reversal of Anticoagulation

Target INR <1.4

4️⃣ ICP Management

Indications:

• GCS <8
• Large hematoma
• Hydrocephalus

Measures:

• Head elevation 30°
• Sedation (propofol)
• Hypertonic saline preferred over mannitol
• Target Na 145–155 in refractory ICP
• Avoid prophylactic hyperventilation

5️⃣ Surgical Management

Indications:

🔹 Cerebellar hemorrhage >3 cm
🔹 Brainstem compression
🔹 Obstructive hydrocephalus
🔹 Lobar ICH with deterioration

Deep basal ganglia bleeds → Usually medical management.

EVD indicated if IVH with hydrocephalus.

6️⃣ Seizure Management

• Treat clinical seizures
• No routine prophylaxis (except lobar hemorrhage sometimes considered)
• Levetiracetam preferred

7️⃣ DVT Prophylaxis

• Intermittent Pneumatic Compression  from day 1
• LMWH after 24–48 hrs if stable CT

8️⃣ Glycemic & Temperature Control

• Target glucose 140–180
• Treat fever aggressively

9️⃣ Hematoma Expansion Prevention

• Early BP control
• Early reversal of anticoagulation
• Avoid platelet transfusion in antiplatelet-related ICH-(unless surgery planned)(PATCH trial -2016)

 Prognostic Factors

Poor outcome predictors:

• Large volume (>60 ml)
• IVH
• Low GCS
• Brainstem bleed
• Advanced age
• Hematoma expansion

Special Situations

🔹 Cerebellar Hemorrhage

• Rapid deterioration
• Early neurosurgical evacuation lifesaving

🔹 Intraventricular Hemorrhage (IVH)

• Causes hydrocephalus
• EVD placement
• Intraventricular alteplase (selected cases)

 Ongoing Trials / Controversies

• MISTIE III (minimally invasive surgery)
• Role of TXA (not routine)
• Intensive BP lowering <130 (not recommended)