9/7/2015 Intracranial Hemorrhage: Background, Pathophysiology, Epidemiology

Intracranial Hemorrhage
Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more...

Updated: Dec 04, 2014

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Background article/1163977-overview#a5
Intracranial hemorrhage (ie, the pathological accumulation of blood within the
cranial vault) may occur within brain parenchyma or the surrounding meningeal
spaces. Hemorrhage within the meninges or the associated potential spaces,
including epidural hematoma, subdural hematoma, and subarachnoid hemorrhage,
is covered in detail in other articles. Intracerebral hemorrhage (ICH) and extension
of parenchymal bleeding into the ventricles (ie, intraventricular hemorrhage [IVH])
are detailed here.

Intracerebral hemorrhage accounts for 8­13% of all strokes and results from a wide
spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or
major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral
hemorrhage and accompanying edema may disrupt or compress adjacent brain
tissue, leading to neurological dysfunction. Substantial displacement of brain
parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal
herniation syndromes.

Pathophysiology
Nontraumatic intracerebral hemorrhage most commonly results from hypertensive
damage to blood vessel walls (eg, hypertension, eclampsia, drug abuse), but it also
may be due to autoregulatory dysfunction with excessive cerebral blood flow (eg,
reperfusion injury, hemorrhagic transformation, cold exposure), rupture of an
aneurysm or arteriovenous malformation (AVM), arteriopathy (eg, cerebral amyloid
angiopathy, moyamoya), altered hemostasis (eg, thrombolysis, anticoagulation,
bleeding diathesis), hemorrhagic necrosis (eg, tumor, infection), or venous outflow
obstruction (eg, cerebral venous thrombosis).

Nonpenetrating and penetrating cranial trauma are also common causes of

intracerebral hemorrhage.Patients who experience blunt head trauma and
subsequently receive warfarin or clopidogrel are considered at increased risk for
traumatic intracranial hemorrhage. According to one study, patients receiving
clopidogrel have a significantly higher prevalence of immediate traumatic
intracranial hemorrhage compared with patients receiving warfarin. Delayed
traumatic intracranial hemorrhage is rare and occurred only in patients receiving
warfarin. [1]

Chronic hypertension produces a small vessel vasculopathy characterized by

lipohyalinosis, fibrinoid necrosis, and development of Charcot­Bouchard aneurysms,
affecting penetrating arteries throughout the brain including lenticulostriates,
thalamoperforators, paramedian branches of the basilar artery, superior cerebellar
arteries, and anterior inferior cerebellar arteries.

Predilection sites for intracerebral hemorrhage include the basal ganglia (40­50%),
lobar regions (20­50%), thalamus (10­15%), pons (5­12%), cerebellum (5­10%), and
other brainstem sites (1­5%).

Intraventricular hemorrhage occurs in one third of intracerebral hemorrhage cases

from extension of thalamic ganglionic bleeding into the ventricular space. Isolated
intraventricular hemorrhage frequently arise from subependymal structures including
the germinal matrix, AVMs, and cavernous angiomas.

Epidemiology
Frequency

United States

Each year, intracerebral hemorrhage affects approximately 12­15 per 100,000

individuals, including 350 hypertensive hemorrhages per 100,000 elderly individuals.
The overall incidence of intracerebral hemorrhage has declined since the 1950s.

International

Asian countries have a higher incidence of intracerebral hemorrhage than other

regions of the world.

Mortality/Morbidity

Annually, more than 20,000 individuals in the United States die of intracerebral
hemorrhage. Intracerebral hemorrhage has a 30­day mortality rate of 44%. Pontine
or other brainstem intracerebral hemorrhage has a mortality rate of 75% at 24
hours. Hallevi et al reviewed the charts and CT scans of patients with
intraventricular hemorrhage (IVH) to determine if the extension of the hemorrhage
could be measured. Clinical outcome was determined by the modified Rankin Scale
(mRS). IVH was also classified with an IVH score. The IVH score allowed rapid
estimate of IVH volume by the practitioner and increased predictability for outcome.
[2]

Race

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9/7/2015 Intracranial Hemorrhage: Background, Pathophysiology, Epidemiology
Intracerebral hemorrhage has a higher incidence among populations with a higher
frequency of hypertension, including African Americans. A higher incidence of
intracerebral hemorrhage has been noted in Chinese, Japanese, and other Asian
populations, possibly due to environmental factors (eg, a diet rich in fish oils) and/or
genetic factors.

Sex

Intracerebral hemorrhage has a slight male predominance, though study results

have been conflicting.

Cerebral amyloid angiopathy may be more common among women.

Phenylpropanolamine use has been associated with intracerebral hemorrhage in

young women. [3]

Age

Incidence of intracerebral hemorrhage increases in individuals older than 55 years

and doubles with each decade until age 80 years. The relative risk of intracerebral
hemorrhage is greater than 7 in individuals older than 70 years.

In individuals younger than 45 years, lobar hemorrhage is the most common site of
and frequently is associated with AVMs.

Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in

premature infants.

Clinical Presentation

Contributor Information and Disclosures

Author
David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program,
University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging
Program, Co­Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke
Center

David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, Stroke
Council of the American Heart Association, American Heart Association, American Medical Association,
American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor­in­Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman,
Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program
Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of
Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American
Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American
Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee
Medical Association

Disclosure: Nothing to disclose.

Chief Editor
Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University
School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American
Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors
Jeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University of
California, Los Angeles, David Geffen School of Medicine

Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of
Neurology, American Heart Association, American Neurological Association, National Stroke Association

Disclosure: Received the university of california regents receive funds for consulting services on clinical trial
design provided to covidien, stryker, and lundbeck. from University of California for consulting.

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