INTRACRANIAL HEMORRHAGE

See also "Neonatal Intracranial Hemorrhage"

I. Etiology

  1. Vascular anomalies
    1. AVM
    2. Angioma
    3. Aneurysm
      1. More common in first-degree relatives of pts with h/o ruptured intracranial aneurysms, though screening such relatives not recc'd as of 2000 (NEM 341:1344, 1999--JW; BMJ 320:141, 2000--JW)
  2. Abnormal arteries (arteritis, amyloid angiopathy)
  3. Bleeding diatheses
  4. Head trauma
  5. Bleeding into preexisting lesions, e.g. tumor
  6. "Spontaneous"--more common in elderly; us. in subcortical WM, basal ganglia, cerebellum & pons; traditionally attributed to chronic HTN, but no h/o HTN in about 50% of pts! Acute rises in BP and reperfusion of ischemic areas may play roles. (edit. in Neurol. 38:624, 4/88)

II. Intracranial hemorrhage associated with IV heparin:

  1. Heparin for Tx of ischemic CVA associated with 0.8% incidence of hemorrhagic stroke; 3.1% incidence of hemorrh. anywhere, with 16% mortality among these
  2. Most pts with hemorrh. complications (anywhere) have PTTs in therapeutic range
  3. Independent risk factors for IC hemorr. secondary to IV Hep post-CVA (or post-TIA or "RIND"):
  1. Rapid (<24 post-sx-onset) onset of CT evidence of cerebral infarction on presentation
  2. Hep loading doses >100U/kg
  3. Total Hep dose >35U/kg/h in 1st 4h
  4. "Severe" neurol. deficits

III. Intracerebral hemorrhage

  1. Treatment
    1. In a study in 1,033 pts with spontaneous intracerebral hemorrhage <72 s/p onset randomized to surgery within 24h of presentation vs. conservative treatment, at 6mos, there were no sig. diffs. in mortality or disability scores, though the subgroup whose hematomas were 1cm or less from cortical surface did show sig. better outcomes with surgery than conservative tx (Lancet 365:387, 2005--JW)
    2. 399 pts with spontaneous intracerebral hemorrhage presenting < 3h after symptom onset randomized to recombinant activated Factor VII ("NovoSeven," one dose, at various doses) within 1h after diagnosis. Repeat CT at 24h showed sig. less 90-day incidence of (death or severe disability) in Factor VII recipients c/w placebo (49-55%, depending on dose, vs. 69% w/placebo). Serious arterial thromboembolic events were sig. more likely in Factor VII recipients (5% vs. 0%) (NEJM 352:777, 2005--JW)