Intracerebral hemorrhage overview

# Overview
Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue and based on the location and size of the bleeding, it may be classified into intraparenchymal hemorrhage, Intraventricular hemorrhage, and cerebral microbleeds. Intracerebral hemorrhage (ICH) usually results from the rupture of small penetrating arteries in the brain near the bifurcation of affected arterioles.  It is thought that ICH may result in brain injury by decreasing blood flow into the area surrounding the clot and causing neuronal ischemia or by overexertion of matrix metalloproteinases (MMPs), which may result in the breakdown of the blood brain barrier and edema. The two major causes of intracerebral hemorrhage include long-standing hypertension and cerebral amyloid angiopathy.
Intracerebral hemorrhage is a medical emergency requiring urgent diagnosis and treatment. If left untreated, it may result in irreversible brain tissue damage. causing permanent neurological deficit and death. Hematoma expansion and early deterioration are common within the first few hours after onset. CT and magnetic resonance imaging (MRI) are both reasonable for initial evaluation. Spontaneous intracerebral hemorrhage (ICH) remains a significant cause of morbidity and mortality throughout the world. However, the excellent medical care has a potent, direct impact on spontaneous intracerebral hemorrhage (ICH) morbidity and mortality. Prevention of intracerebral hemorrhage is mainly aimed at treatment and modifcation of risk factors which are directly associated with increased occurrence of intracerebral hemorrhage.

# Classification
Intracerebral hemorrhage is bleeding within the brain itself. This category includes:

# Pathophysiology
Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue and usually results from rupture of small penetrating arteries in the brain. Degenerative changes in the vessel wall may be associated with advancing age, chronic HTN, diabetes, and other vascular risk factor and It usually occurs at or near the bifurcation of affected arterioles. The exact cause of brain damage following intracerebral hemorrhage is unknown. It is thought that ICH may result in brain injury by decreasing blood flow into the area surrounding the clot and causing neuronal ischemia or by overexertion of matrix metalloproteinases (MMPs), which may result in the breakdown of the blood brain barrier and edema.

# Causes
The two major causes of intracerebral hemorrhage include long-standing hypertension and cerebral amyloid angiopathy. Other causes of intracerebral hemorrhage include vascular malformations (arteriovenous malformations (AVMs)) aneurysms, drugs (cocaineamphetamines), and vasculitis.

# Differential diagnosis
Differential diagnosis of intracerebral hemorrhage may include ischemic stroke, SAH, TIA, acute hypertensive crisis, sentinel headache, sinusitis, hypoglycemia, cerebral venous thrombosis, spontaneous intracranial hypotension, and reversible cerebral vasoconstriction syndrome. It is clinically difficult to distinguish ICH or subarchnoid hemorrhage (SAH) from an ischemic stroke. However, the symptoms like headache, nausea, vomiting, and depressed level of consciousness should raise the suspicion for a hemorrhagic event compared to ischemic stroke.

# Epidemiology
The overall incidence of intracerebral hemorrhage (ICH) ranges from 12 to 31 per 100,000 population. The incidence of intracerebral hemorrhage gets doubled every 10 years after age 35 every, but the prevalence and incidence does not vary by gender. The incidence of intracerebral hemorrhage is the highest in Asians.

# Risk factors
Common risk factors in the development of intracerebral hemorrhage (ICH) include hypertension, anticoagulation medication(warfarin), acquired or congenital coagulation factor disorder (such as vitamin K deficiency, liver disease, disseminated Intravascular Coagulation (DIC), and  hemophilias), platelet abnormalities, embolic strokes, and Sickle Cell Anemia.

# Natural history, Complications, and Prognosis
Intracerebral hemorrhage is a medical emergency requiring urgent diagnosis and treatment. If left untreated, it may result in irreversible brain tissue damage. causing permanent neurological deficit and death. The most common complications following intracerebral hemorrhage (ICH) include hematoma expansion, venous thromboembolism (VTE), pneumonia, apiration, respiratory failure/distress pulmonary embolism, sepsis, neurogenic pulmonary edema, acute respiratory distress syndrome, and acute kidney injury.
Despite aggressive and newer management strategies, the prognosis of patients with intracerebral hemorrhage is very poor. The main powerful predictor of 30-day mortality and morbidity in patients with spontaneous intracerebral hemorrhage is a volume of hemorrhage in combination with the initial Glasgow Coma Scale score (GCS).

# Diagnosis

## Emergency diagnosis and assessment
Intracerebral hemorrhage is a medical emergency, characterized by high morbidity and mortality, which should be promptly diagnosed and aggressively managed. Hematoma expansion and early deterioration are common within the first few hours after onset. CT and magnetic resonance imaging (MRI) are both reasonable for initial evaluation.

## History and Symptoms
It is critical to obtain a detailed and focused history in patient with intracerebral hemorrhage. History of gradual onset of symptoms,Vomiting, hypertension, lipid disorders, smoking, antiplatlete/anticoagulation medication, or illicit drug use, dementia, liver, and chronic kidney disease may suggest intracerebral hemorrhage as one of the initial differential diagnosis..

## Physical examination
Physical examination of patients with Intracerebral hemorrhage usually varies based on the location of the bleeding. Physical examination of patients with intracerebral hemorrhage should include vital signs check and assessment of level of consciousness (GCS) and the severity of the neurological defect (NIHSS).

## Laboratory findings
Routine laboratory studies in patient with intracerebral hemorrhage should include complete blood count (CBC) with platelets,electrolytes, renal function, coagulation studies (prothrombin time (PT), partial thromboplastin time (PTT), and INR), toxicology screen, blood glucose level, and pregnancy test in women of childbearing age.

## Electrocardiogram
Following intracerebral hemorrhage and secondary to catecholamines release following posterior hypothalamus hypoperfusion, the EKG changes may show changes which is a  reflection of left ventricular ischemia. Additionally, brainstem compression may result in ventricular arrhythmias.

## CT
CT is very sensitive for identifying acute hemorrhage and is considered the gold standard.

## MRI
MRI is better than CT for detection of acute and chronic hemorrhage. Therefore it should be the preferred test for accurate diagnosis of patients with suspected intracerebral hemorrhage.

## Other imaging findings
Other imaging findings in diagnosis of intracerebral hemorrhage may include CT angiography (CTA), CT venography (CTV), MR angiography (MRA), MR venography (MRV), and ctheter angiogram.

# Treatment

## Early assessment
Intracerebral hemorrhage (ICH) is a medical emergency. Rapid diagnosis and management is crucial because early deterioration is common in the first few hours after ICH onset.

## Management
Spontaneous intracerebral hemorrhage (ICH) remains a significant cause of morbidity and mortality throughout the world. However, the excellent medical care has a potent, direct impact on spontaneous intracerebral hemorrhage (ICH) morbidity and mortality. The non-surgical management of intracerebral hemorrhage is mainly directed to hemostasis/coagulopathy management, blood pressure (BP) management, glucose/temperature/seizure management, and other medical complications and procedures, including management of intracranial pressure (ICP) and intraventricular hemorrhage.
For AHA/ASA guidelines for the management of ICH, please click here

## Surgery
The indications for surgery in patients with Intracerebral hemorrhage vary with the site of the bleed. Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH. Recently, several studies have shown minimally invasive aspiration associated with better outcomes with less invasive approaches compared to standard craniotomies.

## Primary prevention
Primary prevention of intracerebral hemorrhage is mainly aimed at treatment and modifcation of risk factors which are directly associated with increased occurrence of intracerebral hemorrhage.

## Secondary prevention
Effective measures for the secondary prevention of intracerebral hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and anticoagulation medication avoidance, and enforcing the measures to prevent the complications.