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)- Pathophysiology- presence of small penetrating arteries in deeper lobe with no collaterals.

• 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(Alteplase)

 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
• toxic effects of parenchymal blood

Hematoma expansion occurs in ~30–40% patients within 24 hrs.best predictor of edema volume is the size of the hematoma

5️⃣ Clinical Presentation

• The clinical presentation of ICH is often indistinguishable from that of ischemic stroke.
• Signs and symptoms usually correspond to the location of ICH.
• Blood pressure is elevated in the majority of patients. 

Classic features:

• Sudden headache
• Vomiting
• Decreased GCS
• Focal deficit
• Seizures(15% cases)

6️⃣ Diagnosis

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

• Hyperdense area  surrounded by a rim of hypodensity.(hematoma become isodense with adjacent brain parenchyma by 2–6 weeks.)
• Mass effect
• Midline shift
• Intraventricular extension
• Swirl sign(fresh unclotted blood )

 2. CTA

• Detects spot sign (predicts expansion)- analogous to swirl sign

 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)-

-Premedication should be given to ensure adequate sedation, good jaw relaxation, and to prevent any rise in intracranial pressure (ICP) during the procedure. Short-acting intravenous anesthetic agents such as etomidate or thiopental are used because they help blunt this ICP response and also reduce the brain’s metabolic demand. 

-Among these, etomidate is generally preferred since it is less likely to cause a drop in blood pressure compared to thiopental. -Intravenous lidocaine in a dose of 1–1.5 mg/kg has traditionally been used to further attenuate the rise in ICP, 

-Muscle relaxants are usually not required, but if needed, short-acting agents should be chosen.

• 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
• If SBP >220 mmHg then target SBP 140-160 mmhg
  

Avoid:

• SBP <130 mmHg

Related trials-INTERACT,ATTACH

Preferred IV agents:

• Nicardipine infusion
• Labetalol
• Clevidipine

Avoid nitroprusside (↑ ICP) AND NTG

3️⃣ Reversal of Anticoagulation

• Target INR <1.4
• Routine use of factor VIIa is not recommended

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(The use of phenytoin is discouraged)
• No routine prophylaxis(2015 American Heart Association/American Society of Anesthesiologists )

7️⃣ DVT Prophylaxis

• Intermittent Pneumatic Compression  from day 1
• LMWH after 24–48 hrs if stable CT(THEREFORE DO REPEAT CT TO CHECK HEMATOMA EXPANSION).

8️⃣ Glycemic & Temperature Control

• Target glucose 140–180
• Treat fever aggressively
• Similar to patients with ischemic stroke, ICH patients should not be fed orally until swallowing is evaluated. Dysphagia is a common complication after ICH and a cause for aspiration pneumonia

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)