Skip to main content
SpringerLink
Log in

Intracerebral Hemorrhage

  • Chapter
  • First Online:
Introduction to Vascular Neurosurgery

Abstract

Intracerebral hemorrhage remains one of the most deadly and disabling forms of neurologic disease. The evaluation and management are focused on rapid stabilization and diagnostic testing to rule out the presence of an underlying lesion such as an aneurysm, vascular malformation, or tumor that would require additional testing or treatment in the acute phase. Treatment strategies are limited to control of blood pressure, reversal of anticoagulation, control of intracranial pressure, and supportive care. Surgery is often reserved for the emergent management of increased intracranial pressure or mass effect from the hematoma. Minimally invasive intracerebral hemorrhage evacuation has demonstrated benefit in some settings and is under active investigation in multiple clinical trials. Prognosis overall is poor and is negatively impacted by advanced age, larger hematoma, hematoma located in subcortical locations, the presence of intraventricular hemorrhage, and poor neurologic examination at presentation. Fortunately, significant scientific and translational efforts are underway to develop novel pharmaceutical, device, and data-driven innovations which are likely to lead to novel treatments for this devastating disease process in the near future.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344:1450–60.

    CAS  PubMed  Google Scholar 

  2. Krishnamurthi RV, Feigin VL, Forouzanfar MH, et al. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the global burden of disease study 2010. Lancet Glob Health. 2013;1:e259–81.

    PubMed  PubMed Central  Google Scholar 

  3. Arakawa S, Saku Y, Ibayashi S, Nagao T, Fujishima M. Blood pressure control and recurrence of hypertensive brain hemorrhage. Stroke. 1998;29:1806–9.

    CAS  PubMed  Google Scholar 

  4. Naff NJ, Wemmer J, Hoenig-Rigamonti K, Rigamonti DR. A longitudinal study of patients with venous malformations documentation of a negligible hemorrhage risk and benign natural history. Neurology. 1998;50:1709–14.

    CAS  PubMed  Google Scholar 

  5. An SJ, Kim TJ, Yoon B-W. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. J Stroke Cerebrovasc Dis. 2017;19:3–10.

    Google Scholar 

  6. Tuhrim S. Intracerebral hemorrhage–improving outcome by reducing volume? N Engl J Med. 2008;358:2174–6.

    CAS  PubMed  Google Scholar 

  7. Hemphill JC, Claude Hemphill J, Greenberg SM, et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015;46:2032–60.

    PubMed  Google Scholar 

  8. Sinar EJ, Mendelow AD, Graham DI, Teasdale GM. Experimental intracerebral hemorrhage: effects of a temporary mass lesion. J Neurosurg. 1987;66:568–76.

    CAS  PubMed  Google Scholar 

  9. Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, Spilker J, Duldner J, Khoury J. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997;28:1–5.

    CAS  PubMed  Google Scholar 

  10. Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, Begtrup K, Steiner T, Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006;66:1175–81.

    CAS  PubMed  Google Scholar 

  11. Guo T, Ren P, Li X, Luo T, Gong Y, Hao S, Wang B. Neural injuries induced by hydrostatic pressure associated with mass effect after intracerebral hemorrhage. Sci Rep. 2018;8:9195.

    PubMed  PubMed Central  Google Scholar 

  12. Wu TY, Sharma G, Strbian D, Putaala J, Desmond PM, Tatlisumak T, Davis SM, Meretoja A. Natural history of perihematomal edema and impact on outcome after intracerebral hemorrhage. Stroke. 2017;48:873–9.

    PubMed  Google Scholar 

  13. Murthy SB, Moradiya Y, Dawson J, Lees KR, Hanley DF, Ziai WC, Collaborators VISTA-ICH. Perihematomal edema and functional outcomes in intracerebral hemorrhage: influence of hematoma volume and location. Stroke. 2015;46:3088–92.

    PubMed  Google Scholar 

  14. Aronowski J, Zhao X. Molecular pathophysiology of cerebral hemorrhage: secondary brain injury. Stroke. 2011;42:1781–6.

    PubMed  PubMed Central  Google Scholar 

  15. Wagner KR, Xi G, Hua Y, Kleinholz M, de Courten-Myers GM, Myers RE, Broderick JP, Brott TG. Lobar intracerebral hemorrhage model in pigs: rapid edema development in perihematomal white matter. Stroke. 1996;27:490–7.

    CAS  PubMed  Google Scholar 

  16. Wu G, Wang L, Wang F, Feng A, Sheng F. Minimally invasive procedures for intracerebral hematoma evacuation in early stages decrease perihematomal glutamate level and improve neurological function in a rabbit model of ICH. Brain Res. 2013;1492:140–7.

    CAS  PubMed  Google Scholar 

  17. Wang L, Wu G, Sheng F, Wang F, Feng A. Minimally invasive procedures reduce perihematomal endothelin-1 levels and the permeability of the BBB in a rabbit model of intracerebral hematoma. Neurol Sci. 2013;34:41–9.

    PubMed  Google Scholar 

  18. Lopez Valdes E, Hernandez Lain A, Calandre L, Grau M, Cabello A, Gomez-Escalonilla C. Time window for clinical effectiveness of mass evacuation in a rat balloon model mimicking an intraparenchymatous hematoma. J Neurol Sci. 2000;174:40–6.

    CAS  PubMed  Google Scholar 

  19. Wu G, Zhong W. Effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential and thrombin in dog model of intracranial hemorrhage. Neurol Res. 2010;32:127–33.

    CAS  PubMed  Google Scholar 

  20. Mould WA, Carhuapoma JR, Muschelli J, et al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013;44:627–34.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Mould WA, Muschelli J, Avadhani R, McBee N, Lane K, Thompson R, Ziai W, Zuccarello M, Awad I, Hanley DF. Reduction in perihematomal edema leads to improved clinical outcomes: results from the MISTIE III trial. Stroke. 2019;50:A15.

    Google Scholar 

  22. Claude Hemphill J, Bonovich DC, Besmertis L, Manley GT, Claiborne Johnston S. The ICH score. Stroke. 2001;32:891–7.

    Google Scholar 

  23. Clarke JL, Johnston SC, Farrant M, Bernstein R, Tong D, Hemphill JC 3rd. External validation of the ICH score. Neurocrit Care. 2004;1:53–60.

    PubMed  Google Scholar 

  24. Fiebach JB, Schellinger PD, Gass A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke. 2004;35:502–6.

    PubMed  Google Scholar 

  25. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27:1304–5.

    CAS  PubMed  Google Scholar 

  26. Delcourt C, Carcel C, Zheng D, et al. Comparison of ABC methods with computerized estimates of intracerebral hemorrhage volume: the INTERACT2 study. Cerebrovasc Dis Extra. 2019;9:148–54.

    PubMed  PubMed Central  Google Scholar 

  27. Soun JE, Chow DS, Nagamine M, Takhtawala RS, Filippi CG, Yu W, Chang PD. Artificial intelligence and acute stroke imaging. Am J Neuroradiol. 2021;42:2–11.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. Wei Y, Zhu G, Gao Y, Chang J, Zhang H, Liu N, Tian C, Jiang P, Gao Y. Island sign predicts hematoma expansion and poor outcome after intracerebral hemorrhage: a systematic review and meta-analysis. Front Neurol. 2020 https://doi.org/10.3389/fneur.2020.00429.

  29. Qureshi AI, Ezzeddine MA, Nasar A, Suri MFK, Kirmani JF, Hussein HM, Divani AA, Reddi AS. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25:32–8.

    PubMed  PubMed Central  Google Scholar 

  30. Sakamoto Y, Koga M, Yamagami H, et al. Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. Stroke. 2013;44:1846–51.

    CAS  PubMed  Google Scholar 

  31. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355–65.

    CAS  PubMed  Google Scholar 

  32. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033–43.

    PubMed  PubMed Central  Google Scholar 

  33. Kalisvaart ACJ, Wilkinson CM, Gu S, Kung TFC, Yager J, Winship IR, van Landeghem FKH, Colbourne F. An update to the Monro–Kellie doctrine to reflect tissue compliance after severe ischemic and hemorrhagic stroke. Sci Rep. 2020. https://doi.org/10.1038/s41598-020-78880-4.

  34. Gardner PA, Engh J, Atteberry D, Moossy JJ. Hemorrhage rates after external ventricular drain placement. J Neurosurg. 2009;110:1021–5.

    PubMed  Google Scholar 

  35. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24(Suppl 1):S59–64.

    Google Scholar 

  36. Kamel H, Navi BB, Nakagawa K, Hemphill JC 3rd, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39:554–9.

    CAS  PubMed  Google Scholar 

  37. Flaherty ML, Kissela B, Woo D, Kleindorfer D, Alwell K, Sekar P, Moomaw CJ, Haverbusch M, Broderick JP. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology. 2007;68:116–21.

    CAS  PubMed  Google Scholar 

  38. Huhtakangas J, Tetri S, Juvela S, Saloheimo P, Bode MK, Hillbom M. Effect of increased warfarin use on warfarin-related cerebral hemorrhage. Stroke. 2011;42:2431–5.

    CAS  PubMed  Google Scholar 

  39. Naidech AM, Batjer HH, Bernstein RA. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review. Neurology. 2011;76:1607.

    PubMed  Google Scholar 

  40. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387:2605–13.

    PubMed  Google Scholar 

  41. Naidech AM, Maas MB, Levasseur-Franklin KE, et al. Desmopressin improves platelet activity in acute intracerebral hemorrhage. Stroke. 2014;45:2451–3.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, Symons SP. CT angiography “spot sign” predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007;38:1257–62.

    PubMed  Google Scholar 

  43. Law ZK, Ali A, Krishnan K, et al. Noncontrast computed tomography signs as predictors of hematoma expansion, clinical outcome, and response to tranexamic acid in acute intracerebral hemorrhage. Stroke. 2020;51:121–8.

    PubMed  Google Scholar 

  44. Zhang H-L, Linn J, Bruckmann H, Greenberg SM. Prevalence of superficial siderosis in patients with cerebral amyloid angiopathy. Neurology. 2010;75:1571; author reply 1571

    PubMed  Google Scholar 

  45. Prabhakaran S, Naidech AM. Ischemic brain injury after intracerebral hemorrhage: a critical review. Stroke. 2012;43:2258–63.

    PubMed  Google Scholar 

  46. Flaherty ML, Haverbusch M, Sekar P, Kissela B, Kleindorfer D, Moomaw CJ, Sauerbeck L, Schneider A, Broderick JP, Woo D. Long-term mortality after intracerebral hemorrhage. Neurology. 2006;66:1182–6.

    CAS  PubMed  Google Scholar 

  47. Jolink WMT, Klijn CJM, Paul JA, Jaap Kappelle L, Vaartjes I. Time trends in incidence, case fatality, and mortality of intracerebral hemorrhage. Neurology. 2015;85:1318–24.

    PubMed  Google Scholar 

  48. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993;24:987–93.

    CAS  PubMed  Google Scholar 

  49. Citerio G, Giulia Abate M. Faculty opinions recommendation of clinical grading scales in intracerebral hemorrhage. Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature. 2010. https://doi.org/10.3410/f.4786957.4691055.

  50. Kellner CP, Schupper AJ, Mocco J. Surgical evacuation of intracerebral hemorrhage: the potential importance of timing. Stroke. 2021;52:3391–8. https://doi.org/10.1161/AHA121032238.

    Article  PubMed  Google Scholar 

  51. Morgenstern LB, Demchuk AM, Kim DH. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology. 2001.

    Google Scholar 

  52. Kellner CP, Song R, Ali M, et al. Time to evacuation and functional outcome after minimally invasive endoscopic intracerebral hemorrhage evacuation. Stroke. https://doi.org/10.1161/STROKEAHA.121.034392.

  53. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MDM, Barer DH, STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–97.

    PubMed  Google Scholar 

  54. Mendelow AD, David Mendelow A, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382:397–408.

    PubMed  PubMed Central  Google Scholar 

  55. Gregson BA, Mitchell P, Mendelow AD. Surgical decision making in brain hemorrhage. Stroke. 2019;50:1108–15.

    PubMed  PubMed Central  Google Scholar 

  56. Mckissock W, Richardson A, Taylor J. Primary intracerebral hæmorrhage. Lancet. 1961;278:221–6. https://doi.org/10.1016/s0140-6736(61)90353-1. Accessed 19 Aug 2020

    Article  Google Scholar 

  57. Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, Holzer P, Bone G, Mokry M, Körner E. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989;70:530–5.

    CAS  PubMed  Google Scholar 

  58. Prasad K, Browman G, Srivastava A, Menon G. Surgery in primary supratentorial intracerebral hematoma: a meta-analysis of randomized trials. Acta Neurol Scand. 1997;95:103–10.

    CAS  PubMed  Google Scholar 

  59. Morgan T, Zuccarello M, Narayan R, Keyl P, Lane K, Hanley D. Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. Acta Neurochir Suppl. 2008;105:147–51.

    CAS  PubMed  Google Scholar 

  60. Hanley DF, Thompson RE, Muschelli J, et al. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol. 2016;15:1228–37.

    CAS  PubMed  PubMed Central  Google Scholar 

  61. Vespa P, Hanley D, Betz J, et al. ICES (intraoperative stereotactic computed tomography-guided endoscopic surgery) for brain hemorrhage: a multicenter randomized controlled trial. Stroke. 2016;47:2749–55.

    PubMed  PubMed Central  Google Scholar 

  62. Hanley DF, Thompson RE, Rosenblum M, et al. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet. 2019;393:1021–32.

    PubMed  PubMed Central  Google Scholar 

  63. Kellner CP, Arthur AS, Bain M, Fiorella D, Mocco J. MISTIE III: a big step in the right direction. J Neurointerv Surg. 2019;11:326–7.

    PubMed  Google Scholar 

  64. INVEST feasibility – minimally invasive endoscopic surgery with Apollo in patients with brain hemorrhage. https://clinicaltrials.gov/ct2/show/NCT02654015. Accessed 18 Aug 2020.

  65. MIND: Artemis in the removal of intracerebral hemorrhage. https://clinicaltrials.gov/ct2/show/NCT03342664. Accessed 18 Aug 2020.

  66. Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus. 2013;34:E5.

    PubMed  Google Scholar 

  67. Marinkovic I, Strbian D, Pedrono E, Vekovischeva OY, Shekhar S, Durukan A, Korpi ER, Abo-Ramadan U, Tatlisumak T. Decompressive craniectomy for intracerebral hemorrhage. Neurosurgery. 2009;65:780–6, 1 p following 786; discussion 786

    PubMed  Google Scholar 

  68. Carhuapoma JR, Barrett RJ, Keyl PM, Hanley DF, Johnson RR. Stereotactic aspiration-thrombolysis of intracerebral hemorrhage and its impact on perihematoma brain edema. Neurocrit Care. 2008;8:322–9.

    PubMed  PubMed Central  Google Scholar 

  69. Wang W-Z, Jiang B, Liu H-M, Li D, Lu C-Z, Zhao Y-D, Sander JW. Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China. Int J Stroke. 2009;4:11–6.

    PubMed  Google Scholar 

  70. Rothrock RJ, Chartrain AG, Scaggiante J, Pan J, Song R, Hom D, Lieber AC, Bederson JB, Mocco J, Kellner CP. Advanced techniques for endoscopic intracerebral hemorrhage evacuation: a technical report with case examples. Oper Neurosurg (Hagerstown). 2020. https://doi.org/10.1093/ons/opaa089.

  71. Kellner CP, Chartrain AG, Nistal DA, Scaggiante J, Hom D, Ghatan S, Bederson JB, Mocco J. The stereotactic intracerebral hemorrhage underwater blood aspiration (SCUBA) technique for minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg. 2018;10:771–6.

    PubMed  PubMed Central  Google Scholar 

  72. Kellner CP, Song R, Pan J, et al. Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg. 2020;12:489–94.

    PubMed  PubMed Central  Google Scholar 

  73. Nagasaka T, Tsugeno M, Ikeda H, Okamoto T, Takagawa Y, Inao S, Wakabayashi T. Balanced irrigation-suction technique with a multifunctional suction cannula and its application for intraoperative hemorrhage in endoscopic evacuation of intracerebral hematomas: technical note. Neurosurgery. 2009;65:E826–7; discussion E827

    PubMed  Google Scholar 

  74. Kuo L-T, Chen C-M, Li C-H, Tsai J-C, Chiu H-C, Liu L-C, Tu Y-K, Huang AP-H. Early endoscope-assisted hematoma evacuation in patients with supratentorial intracerebral hemorrhage: case selection, surgical technique, and long-term results. Neurosurg Focus. 2011;30:E9.

    PubMed  Google Scholar 

  75. Troiani Z, Ascanio LC, Yaeger KA, Ali M, Kellner CP. Minimally invasive surgiscopic evacuation of intracerebral hemorrhage. J Neurointerv Surg. 2021;13:400.

    PubMed  Google Scholar 

  76. Labib MA, Shah M, Kassam AB, et al. The safety and feasibility of image-guided BrainPath-mediated transsulcul hematoma evacuation: a multicenter study. Neurosurgery. 2017;80:515–24.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Christina P. Rossitto, J Mocco & Christopher P. Kellner

Authors
  1. Christina P. Rossitto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J Mocco
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher P. Kellner
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christopher P. Kellner .

Editor information

Editors and Affiliations

  1. Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

    Justin R. Mascitelli

  2. Global Neurosciences Institute, Drexel University, Pennington, NJ, USA

    Mandy J. Binning

Rights and permissions

Reprints and permissions

Copyright information

© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Rossitto, C.P., Mocco, J., Kellner, C.P. (2022). Intracerebral Hemorrhage. In: Mascitelli, J.R., Binning, M.J. (eds) Introduction to Vascular Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-030-88196-2_17

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-88196-2_17

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-88195-5

  • Online ISBN: 978-3-030-88196-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation