# Spontaneous Intracerebral Hemorrhage
## Overview
Spontaneous intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and is the most lethal stroke subtype, with 30-day mortality of 30-50%. The most common cause is hypertensive small vessel disease, followed by cerebral amyloid angiopathy (CAA). Surgical management remains controversial, with the STICH trials showing limited benefit for routine craniotomy. Minimally invasive surgical approaches (MISTIE, endoscopic evacuation) represent evolving alternatives with promising early results.
## Etiology
Hypertensive ICH accounts for 55-70% of cases and results from chronic hypertension causing lipohyalinosis and fibrinoid necrosis of small penetrating arteries. Typical locations include the putamen (35%), thalamus (20%), pons (5%), cerebellum (10%), and lobar subcortical white matter. Cerebral amyloid angiopathy accounts for 15-20% and involves amyloid-beta deposition in cortical and leptomeningeal vessel walls, causing predominantly lobar hemorrhages in elderly patients with a recurrence rate of approximately 10% per year.
Other causes include anticoagulant and antiplatelet-related hemorrhage, vascular malformations (AVM, cavernous malformation, dural AVF, especially in young patients), hemorrhage into tumors (melanoma, RCC, choriocarcinoma metastases, or primary GBM), coagulopathy (thrombocytopenia, liver disease, DIC), sympathomimetic drugs (cocaine, amphetamines), Moyamoya disease, and cerebral venous thrombosis causing hemorrhagic venous infarction.
## Clinical Presentation
ICH presents with acute onset of focal neurological deficit progressing over minutes to hours. Headache occurs in 40% of cases, accompanied by vomiting and decreased level of consciousness. Seizures occur in 5-15% in the acute phase. The presentation varies by hemorrhage location. Putaminal hemorrhage produces contralateral hemiparesis, hemisensory loss, hemianopia, and gaze deviation toward the lesion. Thalamic hemorrhage causes contralateral hemisensory loss greater than hemiparesis, downward and medial eye deviation, and aphasia (dominant) or neglect (non-dominant). Pontine hemorrhage produces coma, quadriplegia, pinpoint reactive pupils, hyperthermia, and ocular bobbing. Cerebellar hemorrhage presents with ataxia, vertigo, vomiting, and headache, with risk of rapid deterioration from brainstem compression. Lobar hemorrhage causes deficits corresponding to the affected lobe, with seizures more common.
## ICH Grading and Prognosis
### ICH Score (Hemphill)
The ICH score assigns points based on GCS (2 for 3-4, 1 for 5-12, 0 for 13-15), ICH volume (1 for 30 mL or greater, 0 for under 30 mL), IVH presence (1 point), infratentorial origin (1 point), and age 80 or older (1 point). A score of 0 carries approximately 0% 30-day mortality, while a score of 5 carries approximately 100%. Importantly, the ICH score is prognostic but should not be used for self-fulfilling withdrawal of care decisions.
| Component | Criteria | Points |
|-----------|----------|--------|
| GCS | 13-15 | 0 |
| | 5-12 | 1 |
| | 3-4 | 2 |
| ICH volume | <30 mL | 0 |
| | ≥30 mL | 1 |
| IVH | No | 0 |
| | Yes | 1 |
| Infratentorial origin | No | 0 |
| | Yes | 1 |
| Age | <80 | 0 |
| | ≥80 | 1 |
| ICH Score | 30-Day Mortality |
|-----------|-----------------|
| 0 | ~0% |
| 1 | ~13% |
| 2 | ~26% |
| 3 | ~72% |
| 4 | ~97% |
| 5 | ~100% |
### ICH Volume Estimation (ABC/2 Method)
Volume is estimated as (A x B x C) / 2, where A is the largest hemorrhage diameter on axial CT, B is the perpendicular diameter on the same slice, and C is the number of slices with hemorrhage multiplied by slice thickness, all in centimeters. The result approximates volume in milliliters.
## Imaging
### Non-Contrast CT Head
CT is the first-line imaging modality, identifying hemorrhage location, volume, IVH, and hydrocephalus. The spot sign on CTA indicates active contrast extravasation within the hematoma and predicts hematoma expansion, carrying a poor prognosis. Hematoma expansion occurs in 30-40% of cases within the first 24 hours and is the strongest modifiable predictor of poor outcome.
### CTA/MRI
CTA is used to identify underlying vascular lesions (AVM, aneurysm) in patients under 55, those with lobar location, or atypical hemorrhage patterns. MRI with GRE/SWI detects microbleeds: a lobar pattern suggests CAA while a deep pattern suggests hypertensive vasculopathy. MR venography is obtained if venous thrombosis is suspected.
Non-contrast CT head showing a large left putaminal intracerebral hemorrhage with mass effect, midline shift, and intraventricular extension into the left lateral ventricle. An adjacent CTA shows the "spot sign" (active contrast extravasation within the hematoma, indicated by an arrow). The ABC/2 method for volume estimation is demonstrated on a separate panel with measurements. Key imaging features including ICH volume, IVH, and midline shift are annotated. Radiological teaching illustration.
## Medical Management
### Blood Pressure Control
AHA/ASA guidelines recommend acute lowering of systolic blood pressure to 140 mmHg as safe and potentially beneficial for reducing hematoma expansion. The INTERACT2 trial showed that intensive BP lowering (SBP under 140 within 1 hour) compared with standard treatment (SBP under 180) produced a non-significant trend toward better functional outcomes on ordinal analysis. ATACH-2 compared intensive (SBP 110-139) with standard (SBP 140-179) and found no significant difference in outcome, with more renal adverse events in the intensive group. Preferred agents include titratable IV nicardipine infusion, labetalol, and clevidipine. Precipitous drops should be avoided and SBP should be maintained at 110 mmHg or above.
### Coagulopathy Reversal
For warfarin-associated ICH, treatment involves IV vitamin K (10 mg slow infusion) plus 4-factor prothrombin complex concentrate (25-50 units/kg), targeting INR of 1.3 or below within 4 hours; FFP is inferior to PCC. For DOACs, idarucizumab reverses dabigatran and andexanet alfa reverses factor Xa inhibitors (rivaroxaban, apixaban), with 4-factor PCC as an alternative. Platelet transfusion is not recommended for ICH in patients on antiplatelet therapy, as the PATCH trial showed worse outcomes with platelet transfusion. Heparin is reversed with protamine sulfate. Platelet transfusion is appropriate only if platelet count is below 100,000 and surgical intervention is planned.
### Hemostatic Therapy
Recombinant factor VIIa reduced hematoma expansion in the FAST trial but did not improve clinical outcomes and increased thromboembolic events; it is not recommended routinely. Tranexamic acid in the TICH-2 trial reduced hematoma expansion but showed no functional benefit at 90 days; further trials are ongoing.
### General ICU Management
ICP monitoring and management is appropriate if GCS is 8 or below with clinical signs of raised ICP. Seizure prophylaxis is not routinely recommended, but clinical seizures are treated with levetiracetam. DVT prophylaxis uses pneumatic compression immediately, with subcutaneous heparin added after 24-48 hours once hemorrhage is stable. Glucose is managed to avoid hyperglycemia (target 140-180 mg/dL). Normothermia is maintained and dysphagia screening precedes oral intake.
## Surgical Management
### STICH Trial (2005)
This trial randomized 1,033 patients with supratentorial ICH to early surgery (craniotomy within 24 hours) versus initial conservative treatment. There was no overall benefit of early surgery. Subgroup analysis suggested possible benefit for lobar hemorrhages within 1 cm of the cortical surface.
### STICH II (2013)
This trial enrolled 601 patients with lobar ICH within 1 cm of the cortical surface (10-100 mL, without IVH, GCS 5 or above). There was no significant benefit of early surgery over initial conservative treatment, though 21% of the conservative group crossed over to surgery.
### Indications for Craniotomy
Cerebellar hemorrhage greater than 3 cm or with brainstem compression or obstructive hydrocephalus is a surgical emergency. Other indications include lobar hemorrhage with clinical deterioration despite maximal medical therapy, young patients with large accessible lobar hematoma and progressive decline, and underlying structural lesions (AVM, tumor) requiring surgical treatment.
### Minimally Invasive Surgery
#### MISTIE Trials
The MISTIE II and III trials evaluated stereotactic catheter placement into the hematoma with low-dose tPA instillation (1 mg every 8 hours) to lyse and drain the clot. MISTIE III (2019) showed that reduction to 15 mL or less of residual clot was associated with better functional outcomes, but the overall trial did not meet its primary endpoint (mRS 0-3 at 365 days). The concept is that gradual clot lysis and drainage reduces perilesional edema, secondary injury, and mass effect.
#### Endoscopic Evacuation
The ENRICH trial evaluated endoscopic ICH evacuation versus standard medical care for lobar and anterior basal ganglia ICH (30-80 mL); results suggest benefit of early endoscopic evacuation for lobar ICH. Advantages include direct visualization, immediate clot removal, and less brain trauma than craniotomy. Techniques include the NICO BrainPath (endoport-based), Apollo system, and neuroendoscopy with suction.
### Intraventricular Hemorrhage and EVD
IVH occurs in 40-50% of ICH cases and is an independent predictor of poor outcome. EVD is indicated for obstructive hydrocephalus. The CLEAR III trial evaluated intraventricular tPA (1 mg every 8 hours via EVD) for IVH and found reduced mortality (18% versus 29%) but no improvement in good functional outcome (mRS 0-3).
Comparison of surgical approaches for intracerebral hemorrhage. Panel 1: Standard craniotomy with bone flap elevation and direct hematoma evacuation under microscopic guidance. Panel 2: Minimally invasive catheter-based approach (MISTIE technique) with stereotactic catheter insertion and low-dose tPA instillation for clot lysis. Panel 3: Endoscopic evacuation through a small burr hole using an endoport with direct visualization and suction of the hematoma. Each panel shows the approach, key steps, and postoperative CT with reduced hematoma volume. Surgical teaching illustration.
## Cerebellar Hemorrhage
Cerebellar hemorrhage greater than 3 cm with brainstem compression or obstructive hydrocephalus is a surgical emergency requiring suboccipital craniectomy with hematoma evacuation. EVD manages hydrocephalus but is insufficient alone if the mass causes brainstem compression. Outcome is significantly better with timely surgical intervention than with conservative management for large cerebellar hemorrhages. Rapid neurological deterioration can occur within hours.
## Clinical Pearls
Cerebellar hemorrhage greater than 3 cm with brainstem compression is one of the clearest surgical indications in all of neurosurgery, and surgery should not be delayed. The ICH score should not be used to justify withdrawal of care, as early withdrawal is a self-fulfilling prophecy and the leading cause of death in ICH; aggressive early management improves outcomes. Hematoma expansion is the strongest modifiable predictor of poor outcome, making rapid BP control and coagulopathy reversal within the first hours critical interventions. Platelets should not be transfused for ICH in patients on antiplatelet therapy, as the PATCH trial showed worse outcomes. The spot sign on CTA predicts hematoma expansion and should trigger more aggressive medical management and closer monitoring. Lobar ICH in elderly patients with microbleeds should raise suspicion for cerebral amyloid angiopathy, which has a high recurrence rate and precludes long-term anticoagulation. STICH showed no benefit for routine craniotomy, but this does not mean surgery has no role; minimally invasive approaches and cerebellar hemorrhage evacuation are established surgical indications.
## References
- Hemphill JC 3rd, et al. "The ICH Score: A Simple, Reliable Grading Scale for Intracerebral Hemorrhage." *Stroke*. 2001;32(4):891-897.
- Mendelow AD, et al. "Early Surgery versus Initial Conservative Treatment in Patients with Spontaneous Supratentorial Intracerebral Haematomas (STICH)." *Lancet*. 2005;365(9457):387-397.
- Hanley DF, et al. "Efficacy and Safety of Minimally Invasive Surgery with Thrombolysis in Intracerebral Haemorrhage Evacuation (MISTIE III)." *Lancet*. 2019;393(10175):1021-1032.
- Anderson CS, et al. "Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage (INTERACT2)." *NEJM*. 2013;368(25):2355-2365.
- Greenberg SM, et al. "2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage." *Stroke*. 2022;53(7):e282-e361.