FFS: Cerebral haemorrhage

Stroke refers to a vascular event causing a focal neurological deficit lasting >24 hours. Use of specific terms—cerebral infarction or cerebral haemorrhage—is preferred, as these represent distinct entities with different management.

Pathophysiology

Causes of cerebral haemorrhage:

1. Hypertension:
   • Common locations:
     • Basal ganglia
     • Cerebellum
     • Brainstem: midbrain, pons, medulla
   • Haemorrhage outside these typical regions suggests alternative pathology.
2. Amyloid angiopathy:
   • Seen in elderly; lobar distribution
3. Subarachnoid haemorrhage (SAH)
4. Secondary causes:
   • Trauma
   • Coagulopathy
   • Tumour
   • AV malformation
   • Infection
   • Vasculitis

Complications

• Raised intracranial pressure: ↓ consciousness, airway compromise
• Intraventricular extension → hydrocephalus
• Seizures
• Aspiration pneumonia
• Long-term neurological deficits

Clinical assessment

History clues suggesting haemorrhage:

• Sudden headache, nausea/vomiting
• Altered consciousness
• Seizures
• Sudden collapse

Medications: warfarin, DOACs
Comorbidities and baseline function impact management.

Examination essentials:

1. Airway, breathing, circulation; check gag reflex
2. Blood glucose
3. Neurological status: GCS, localising signs

Stroke syndromes (less distinct in haemorrhage than infarction):

• Anterior circulation (carotid):
  • ACA: contralateral leg weakness
  • MCA: face/arm > leg weakness, aphasia, neglect, gaze deviation
• Posterior circulation (vertebrobasilar):
  • PCA: visual disturbances, cortical blindness
  • Brainstem/cerebellum: vertigo, diplopia, dysarthria, ataxia, crossed signs

Stroke severity scoring:

• Use NIHSS (formal), FAST (initial screening)

Assessment of severity

ICH Score (predicts mortality):

1. GCS
2. Age ≥ 80
3. ICH volume ≥ 30 mL (via ABC/2 method)
4. Intraventricular extension
5. Location: supratentorial vs infratentorial

See related documents: ICH Score, Volume Estimation.

Differential diagnoses

• Tumours
• Subdural/extradural haematoma
• Venous sinus thrombosis
• Metabolic: hypo/hyperglycaemia, hyponatraemia, Wernicke’s
• Todd’s paresis
• Demyelination
• Functional disorders

Investigations

Blood tests:

• FBC
• U&Es / glucose
• Coagulation profile (especially for anticoagulant use)
• ESR/CRP (vasculitis)

ECG: may show nonspecific changes
CXR: check for aspiration in decreased GCS

CT brain (non-contrast): essential for all suspected strokes

• Rules out:
  • ICH, SAH, extra-axial bleeds
  • Stroke mimics (tumour, venous thrombosis)

Typical hypertensive bleed sites:

• Brainstem
• Cerebellum
• Basal ganglia

Signs of raised ICP:

• Sulcal effacement
• Midline shift
• Ventricular compression
• Quadrigeminal cistern obliteration (“smiley face”)

CT angiogram:

• Detects:
  • Vascular malformations (AVMs, aneurysms)
  • Ongoing bleeding (“spot sign”)

CT spot sign:

• Active contrast leak into haematoma on CTA
• Predicts haematoma expansion and poor outcome

CT swirl sign:

• On non-contrast CT, shows active bleeding (unclotted blood)

Scan urgency:
Prioritise if:

• Thrombolysis/thrombectomy candidate
• Suspected SAH
• ↓ GCS
• Coagulopathy or anticoagulant use

MRI/A:

• MRI may clarify diagnosis if CT inconclusive
• MRA useful for underlying lesions

Management

General approach:

1. ABC resuscitation
2. Supplemental O₂ if saturations < 95%
3. IV access and fluids (avoid glucose)
4. Nil orally pending swallowing assessment
5. Anticoagulation reversal:
   • Warfarin: Vit K + prothrombinex + FFP
   • DOACs: idarucizumab (dabigatran), andexanet alfa (Xa inhibitors)
6. Glucose management:
   • Avoid both hypo- and hyperglycaemia
7. IDC for reduced GCS or nursing needs
8. Hypertension control:
   • Target SBP ≈140 mmHg
   • IV options: hydralazine, GTN, esmolol, labetalol, nicardipine
9. Antiplatelet reversal:
   • Do not give platelets unless active bleeding or procedure
10. Pyrexia: treat if T > 37.5°C

Specific considerations

SAH:

• Urgent neurosurgical referral

Posterior fossa haemorrhage:

• Cerebellar bleed >3 cm = urgent surgical decompression
• Brainstem haemorrhage = poor prognosis; discuss with neurosurgery

Supratentorial ICH:

• Surgery not routinely beneficial
• Discuss with neurosurgery if:
  • Young patient, good premorbid state
  • Hydrocephalus
  • Mass effect
  • Presenting <24 hrs

Decision factors:

• Age < 80
• Baseline function
• GCS 5–15 or severe focal deficit
• CT findings
• Family expectations
• Likelihood of survival and recovery

Surgery should occur within 72 hours if indicated.

Disposition

• SAH or posterior fossa ICH: urgent transfer to neurosurgical centre
• Supratentorial ICH: transfer if surgery indicated
• Others: admit to stroke unit

Plan for possible deterioration. Decisions regarding treatment limitations should be made early, especially for high-risk patients.

In younger patients, consider early transfer to neurosurgical facility if deterioration may require surgical intervention.

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Appendix 1

Large intracerebral haemorrhage in the region of the basal ganglia – a typical – “hypertensive” site for bleeding. There is significant mass effect with midline shift, effacement of sulci and obliteration of the right lateral ventricle.

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Appendix 2

Intracerebral Haemorrhage Volume Estimation:

Calculation Method:

Estimated volume of an ellipsoid lesion = A x B x C / 2

• A = greatest haemorrhage diameter in the axial plane
• B = haemorrhage diameter at 90º to A in the axial plane
• C = originally described as the number of CT slices with haemorrhage multiplied by the slice thickness, but can simply be substituted with the cranio-caudal diameter of the haemorrhage where there is access to multiplanar reformats

If the measurements are made in centimetres (cm), then the volume will be in cubic centimetres (cc). Note that 1 cm³ = 1 ml

Interpretation:

• An ICH volume of  ≥ 30ml is one of 5 parameters thatpredicts a more serious hemorrhage within the Intracerebral Hemorrhage (ICH) Score     
• A baseline intracerebral haemorrhage volume of  > 50 – 60 ml is a poor prognostic marker.

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Appendix 3

The Intracerebral Haemorrhage (ICH) Score

Scoring method:

Parameter	Result	Score
Glasgow Coma Score (GCS)	13–15	0
	5–12	1
	3–4	2
Age ≥ 80	No	0
	Yes	1
ICH volume ≥ 30 mL	No	0
	Yes	1
Intraventricular haemorrhage	No	0
	Yes	1
Origin of haemorrhage	Supratentorial	0
	Infratentorial	1

Interpretation:

ICH Score	30-day mortality
0	0%
1	13%
2	26%
3	72%
4	94%
5	100%
6	100%

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References

Publications

• Sharma R. CT angiographic spot sign (intracerebral haemorrhage). Radiopaedia
• Kusel K. Swirl sign (intracranial haemorrhage). Radiopaedia
• Clinical Guidelines for Acute Stroke Management – National Stroke Foundation
• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Fuller G. Neurological Examination Made Easy. 6e 2019
• O’Brien M. Aids to the Examination of the Peripheral Nervous System. 6e 2023

FOAMed

• Gibbs M. Neuroimaging Cases 004. LITFL
• Flower O. EVACUATE: ICH Management. LITFL
• Suresh Kochath P. CT Case 078. LITFL
• Lam L. CT Case 022. LITFL
• Coni R. Neuro 101: Cerebral Hemispheres. LITFL