EM · Intracerebral haemorrhage

Intracerebral haemorrhage

Also known as Intraparenchymal haemorrhage · Spontaneous intracerebral haemorrhage · Hypertensive haemorrhage · Lobar haemorrhage

Intracerebral haemorrhage is the spontaneous, non-traumatic bleeding into the brain parenchyma, most often from hypertensive small-vessel disease in the deep structures (the putamen, the thalamus, the pons, the cerebellum) or cerebral amyloid angiopathy in the elderly (the lobar haemorrhage). It presents with a sudden focal deficit, headache, vomiting, a depressed conscious level and marked hypertension. The non-contrast CT shows a hyperdense mass with mass effect, midline shift and intraventricular extension, graded by the Graeb score and the ICH score. Management is blood-pressure control to a systolic target of 140 mmHg (labetalol 10 to 20 mg IV or nicardipine 5 to 15 mg/h), urgent reversal of anticoagulation (prothrombin complex concentrate 25 to 50 IU/kg plus vitamin K 10 mg for warfarin; idarucizumab 5 g for dabigatran; andexanet alfa for apixaban or rivaroxaban), intracranial-pressure control (head elevation 30 degrees, mannitol 0.5 g/kg or hypertonic saline 3 per cent 250 mL), and neurosurgical evacuation for a cerebellar haematoma over 3 cm or a deteriorating lobar clot. ACEM-primary, globally tagged.