Intracerebral Hemorrhage

This section will discuss intracerebral hemorrhage; the commonest type of hemorrhagic stroke. Hemorrhagic stroke is a broad category of stroke and includes intracerebral hemorrhage and subarachnoid hemorrhage. Together these two conditions represent 13-20% of stroke cases with the rest being due to ischemic stroke. Intracerebral hemorrhage is more common than subarachnoid hemorrhage with the later representing approximately 5% of all strokes.
Intracerebral hemorrhage presents with sudden onset focal neurological deficit. This may be accompanied by a headache and nausea. The main differential diagnosis is ischemic stroke. Subarachnoid hemorrhage presents with sudden severe headache. In more severe cases patients with either condition may present in coma.
The conditions are separate with different etiology and management strategies. Please see other sections if necessary.
The overall commonest cause of intracerebral hemorrhage is hypertension. In patients older than 70 years, cerebral amyloid angiopathy is the commonest cause. The commonest cause in children is cerebral arteriovenous malformations (AVM).


Intraparenchymal hemorrhage (IPH), intracerebral hematoma, intracerabral haemorrahge

Causes of intracerebral hemorrhage ICH: ‘hemorrhagic stroke’:


  • Hypertension
  • Small vessel disease
  • Cerebral amyloid angiopathy CAA (hemorrhagic)- Arteriovenous malformations AVM
  • Reversible cerebral vasoconstriction syndrome (RCVS)
  • Cerebral vasculitis
  • Posterior reversible encephalopathy syndrome (PRESS)


  • Cavernous malformations a.k.a. Cavernous hemangiogma a.k.a. cavernoma
  • Cerebral Venous sinus thrombosis (venous sinus, deep veins, cortical veins)
  • Venous thrombosis


  • Coagulopathy: Systemic bleeding disorders, Anticoagulant therapy

Hemorrhagic tumours (intra-tumoural hemorrhage):

  • Metastasis: melanoma, renal cell carcinoma, choriocarcinoma, thyroid, bronchogenic carcinoma
  • High grade astrocytoma: anaplastic astrocytoma, glioblastoma
  • Others: schwannoma, pituitary adenoma, meningioma, hemangioblastoma



  • Hyperdense, sharp margin
  • Surrounding hypodensity: oedema
  • Possible mass effect
  • Single or multiple
  • If traumatic CT appearance might be delayed >24hrs
  • Variation with time:
    • Acute: hyperdense +oedema
    • Weeks: isodense
    • Months: hypodense, dilated adjacent sulci & ventricle

ABC/2 method of measuring hemorrhage volume:

  • A= greatest hemorrhage diameter
  • B= diameter 90 degrees to A
  • C= number of CT slices with hemorrhage X slice thickness.
  • Slices with hemorrhage:
  • Slices with hemorrhage >75% of A count as 1 slice
  • Slices with hemorrhage 25-75% count as 0.5 slice


  • Gradient echo MRI: Best to detect old hemorrhage in stroke with delayed presentation. Acute or old Hemorrhage: low signal
  • Assesses causes: AVM, Cavernous malformation, underlying neoplasm, features of cerebral amyloid angiopathy (old hemorrhages), hemorrhagic PRESS, cerebral venous thrombosis CVT, cerebral vasculitis

ICH score:

Add scores for the follwoing parameters:

  • Glasgow coma scale
  • Age ≥ 80
  • ICH Volume ≥ 30ml
  • Presence of intraventricular hemorrhage IVH
  • Infratentorial origin of hemorrhage

Glasgow Coma Score:

  • +2 points for GCS 3-4
  • +1 points for GCS 5-12
  • 0 points for 13-15

Age ≥ 80

  • 1 point for YES
  • 0 points for NO

ICH Volume ≥ 30ml

  • 1 point for YES
  • 0 points for NO

Intraventricular Hemorrhage

  • 1 point for YES
  • 0 points for NO

Infratentorial Origin of Hemorrhage

  • 1 point for YES
  • 0 points for NO


  • Depends on cause, see cerebral amyloid angiopathy, cavernoma, AVM, cerebral aneurysms
  • Acute: hemorrhage (RBC), disruption of brain tissue,
  • Charcot-Bouchard aneurysms in hypertensive intracerebral hemorrhage. Not true aneurysms but represent tortuous perforator blood vessels
  • Genetic forms: COL4A1 gene mutations are associated with small vessel disease & hemorrhagic stroke

Investigations to consider:


  • To assess for underlying vascular malformation
  • May be negative in dural arteriovenous fistula DAVF
  • MRV: to rule out venous sinus thrombosis CVST, deep cerebral vein thrombosis, cortical vein thrombosis


  • To assess for underlying vascular malformation
  • May be negative in dural arteriovenous fistula DAVF
  • CT venogram, or MRV: to rule out venous sinus thrombosis CVST, deep cerebral vein thrombosis DCVT, cortical vein thrombosis

Catheter angiography, Digital Subtraction Angiography DSA:

  • Repeat or delayed Angiography may be needed to rule out AVMs as angiography can be false-negative in acute hemorrhage
  • Best test for AVM
  • Best test for dural arteriovenous fistula DAVF
  • Helps evaluate cerebral venous sinus thrombosis CVST, Reversible cerebral vasoconstriction syndrome (RCVS), Cerebral vasculitis

Blood tests:

  • FBC, blood chemistry panel, coagulation screen
  • Blood cultures X3: if suspecting infective endocarditis
  • Tests for coagulopathy as appropriate

Speech and language therapy assessment:

  • Dysphagia Screening: 10 ml water swallow: coughing, choking or wet quality of voice
  • Test feeds

Videofluroscopy: be aware of normal aging changes

  • May demonstrate features of chronic hypertension, LVH, cardiomyopathy.
  • Infective endocarditis with septic embolism ‘mycotic aneurysm’

Brain Biopsy: cerebral amyloid angiopathy


  • Avoid do not resuscitate (DNR) orders for the first 24-48 hours
  • The maintain treatment is medical and supportive care. There is a small role for surgery
  • Treat the underlying condition if present: AVM, DAVF, coagulopathy, cerebral venous sinus thrombosis,


  • Temperature: Acetaminophen/paracetamol if >37 degrees. [post hoc of RCT]
  • Blood pressure control:
    • Keep BP<140 mmHg systolic [INTERACT RCT]
    • Consider using nicardipine IV infusion, labetalol IV infusion, nitroglycerin paste
    • Avoid: Nitroprusside may raise ICP [theoretical concerns]
  • Medical management of cerebral edema as necessary: hyper-osmolar therapy
  • Airway management, mechanical ventilation as necessary
  • Swallow assessment and feeding with efforts to avoid aspiration pneumonia
  • Glycemic control: by insulin sliding scale or if necessary insulin infusion
  • DVT prophylaxis with enoxaparin or heparin subcutaneously is safe on day 2. [Prospective study]

Consider Surgery:

  • Limited role. Not useful in deep hemorrhages. Not useful in most cortical hemorrhages either. [STICH, STICH2] Minimally invasive surgery (MIS) techniques are promising but require further study in randomized controlled trials.
  • For cerebellar hemorrhage, consider cerebellar decompression: craniotomy +evacuation under direct vision
  • Consider external ventricular drain (EVD) for intraventricular hemorrhage. No benefit for additional intra-ventricular alteplase. [CLEAR-IVH]


  • Safe to start day 2 after ICH
  • Core components:
    • Early mobilization
    • Speech & language therapy
    • Physical therapy
    • Occupational therapy

Oral Anticoagulant associated ICH:

  • Expand over a long period, up to 7 days
  • Hemorrhage is common
  • Fluid-fluid level may occur
  • Same as spontaneous ICH except reverse the agent.
  • Prothrombin complex concentrate (PCC) for warfarin induced ICH
  • Idarucizumab (trade name= Praxbind) for dabigatran induced ICH


Related articles:

Approach to weakness, approach to abnormal speech,


  1. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069.
  2. Kothari, R.U., et al., The ABCs of measuring intracerebral hemorrhage volumes. Stroke, 1996. 27(8): p. 1304-5.
  3. Boeer, A., et al., Early heparin therapy in patients with spontaneous intracerebral hemorrhage. J Neurol Neurosurg Psychiatry, 1991. 54(5): p. 466-7.
  4. Geocadin, R.G., et al., Intracerebral hemorrhage and postpartum cerebral vasculopathy. J Neurol Sci, 2002. 205(1): p. 29-34.
  5. Hemphill et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001, 32:891-897