Causes of ICH
The direct cause of injury is hypertension,
however this can be associated with a number of
Such as :
Hypertension, amyloid angiopathy, ruptured saccular
aneurysm, vascular malformation as well as
iatrogenic drug therapy induced bleeding which
account for the majority of cases.
Clinical Manifestations Hypertensive ICH
Will depend on the area of the brain that gets affected.
Putaminal, Cerebellar, Thalamic, Lobar, and Pontine
hemorrhages are the main hemorrhages observed.
Extension of parenchymal bleeding of ICH into the
ventricles is intraventricular hemorrhage [IVH]
The neurologic symptoms usually increase gradually over
minutes or a few hours. In contrast to brain embolism and
subarachnoid hemorrhage, the neurologic symptoms do not
begin abruptly and are not maximal at onset.
Headache, vomiting, a decreased level of consciousness and
seizures are common.
Stupor or coma in ICH is an ominous sign of diffuse brain
Some patients have abnormalities on ECG, including a
prolonged QT interval, depressed ST segment, flat or inverted T
waves, U waves, and tall peaked T waves.
Hemiplegia, hemisensory loss, homonymous hemianopsia,
gaze palsy, stupor, and coma.
Imbalance, vomiting, headache, neck stiffness, gaze palsy,
and facial weakness. The patient may become stuporous
from brainstem compression over time. Cerebellar
hemorrhage is a crucial diagnosis to make since these
patients frequently deteriorate and require surgery.
Hemiparesis, hemisensory loss There may also be an upgaze
palsy with miotic pupils that are unreactive, and eyes that
deviate to the affected side.
Symptoms vary considerably and injury most often
affects the parietal and occipital lobes and are associated
with a higher incidence of seizures.
These often lead to deep coma over the first few
minutes. The motor examination is marked by total
paralysis. The pupils are pinpoint and react to a strong
light source. Horizontal eye movements are absent, and
there may be ocular bobbing, facial palsy, deafness, and
dysarthria when the patient is awake.
Evaluating Intracerebral Hemorrhage
ICH score — A simple six-point clinical grading scale
called the ICH score has been devised to predict
mortality after ICH
The ICH score is determined as follows:
Glasgow Coma Scale (GCS) score 3 to 4 (= 2
points); GCS 5 to 12 (= 1 point) and GCS 13 to 15
(= 0 points)
ICH volume 30 cm3 (= 1 point), ICH volume <30
cm3 (= 0 points)
Intraventricular extension of hemorrhage present (=
1 point); absent (= 0 points)
Infratentorial origin yes (= 1 point); no (= 0 points)
Age 80 (= 1 point); <80 (= 0 points)
Cheung et al. (2003) validated the ICH score by
retrospective analysis indicating it as a better
predictor of outcome than the Glasgow coma
Thirty-day mortality rates increased steadily with
ICH score; mortality rates for ICH scores of 1,
2, 3, 4, and 5 were 13, 26, 72, 97, and 100
percent, respectively. No patient with an ICH
score of 0 died, and none had a score of 6 in the
Cheung, RT, Zou, LY. Use of the original,
modified, or new intracerebral hemorrhage score
to predict mortality and morbidity after
intracerebral hemorrhage. Stroke 2003; 34:1717.