Spontaneous intracerebral haemorrhage: Α review
ZEVGARIDIS D., TSONIDIS C., NANASSIS K., ANAGNOSTOPOULOS I., TSITSOPOULOS P., TSITSOPOULOS Ph.

Spontaneous intracerebral haemorrhage (SICH) is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10 to 15% of all strokes. It is twice as common as subarachnoid haemorrhage (SAH) and is much more likely to result in death or major disability than cerebral infarction or SAH. SICH occurs slightly more frequently among men than women and is significantly more common among young and middle-aged blacks than whites of similar ages. Reported incidence rates of SICH among Asian populations are also higher than those reported for whites in the United States and Europe.

Pathophysiological change in small arteries and arterioles due to sustained hypertension is generally regarded as the most important cause of SICH. Cerebral amyloid angiopathy is increasingly recognized as a cause of lobar SICH in the elderly. Other causes of SICH include vascular malformations, ruptured aneurysms, coagulation disorders, use of anticoagulants and thrombolytic agents, haemorrhage into a cerebral infarct, bleeding into brain tumours, and drug abuse.

The classic presentation of SICH is sudden onset of a focal neurological deficit that progresses over minutes to hours with accompanying headache, nausea, vomiting, decreased consciousness, and elevated blood pressure. The early progression of neurological deficit in many patients with a SICH is frequently due to ongoing bleeding and enlargement of the haematoma during the first few hours.

Computed tomography (CT) is the key part of the initial diagnostic evaluation. It clearly differentiates haemorrhagic from ischemic stroke. CT also demonstrates the size and location of the haemorrhage and may reveal structural abnormalities such as aneurysms, arteriovenous malformations, and brain tumours that caused the SICH as well as structural complications such as herniation, intraventricular haemorrhage, or hydrocephalus. Administration of contrast by the radiologist can often highlight suspected vascular abnormalities. Angiography should be considered in all cases except those involving older patients with pre-existing hypertension in thalamic, putaminal, or cerebellar haemorrhage. Timing of cerebral angiography depends on the patient's clinical state and the neurosurgeon's judgement about the urgency of surgery, if needed. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as other useful tools for detecting structural abnormalities such as malformations and aneurysms. Other useful diagnostic tools include a complete blood count, prothrombin time activated partial thromboplastin time, electrolytes, electrocardiography, and chest x-ray.

Medical management includes venous thrombosis prophylaxis, gastric cytoprotection, and aggressive rehabilitation. Anticolvusant agents should be prescribed in supratentorial SICH. The management of hypertension is controversial. The optimal level of a patient's blood pressure should be based on individual factors such as chronic hypertension, elevated intracranial pressure (ICP), age, presumed cause of haemorrhage, and interval since onset. The American Heart Association recommends that blood pressure levels be maintained below a mean arterial pressure of 130 mmHg in persons with a history of hypertension. Cerebral perfusion pressure should be kept above 70 mmHg. Elevated intracranial pressure (ICP) may be managed through optimal head position, osmotherapy, controlled hyperventilation, and barbiturate coma.

To date, ten prospective, randomized, controlled studies have been conducted to compare surgical and medical management of SICH. Although definitive evidence favoring surgical intervention is lacking, there is good theoretical rationale for early surgical intervention. Surgery should be considered in patients with moderate to large lobar or basal ganglia haemorrhages and those suffering progressive neurological deterioration. Elderly patients in whom the Glasgow Coma Scale is less than 5, those with brainstem haemorrhages, and those with small haemorrhages do not typically benefit from surgery. Patients with cerebellar haemorrhages larger than 3 cm, those with brainstem compression and hydrocephalus, or those exhibiting neurological deterioration should undergo surgical evacuation of the clot.

Key words: Spontaneous Intracerebral Haemorrhage, epidemiology, conservative therapy, operative treatment, surgery.