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  • 12–31 per 100,000 people
  • 10–30% of all strokes
  • Six-month mortality rate of 30–50%
  • Only 20% regain functional independence at end of 6 months


  • Men
  • African-Americans, Japanese
  • Low LDL cholesterol, Hypertension
  • Excessive alcohol consumption
  • Anticoagulation


  • Ischemic stroke with hemorrhagic conversion
  • Amyloid angiopathy (age >60 years)
  • Chronic hypertension
  • Coagulopathy
  • AV malformation, cavernous angioma, neoplasm, dural sinus thrombosis with hemorrhage
  • Vasculopathy
  • Trauma


  • Hemorrhages continue to grow and expand over several hours after onset of symptoms (hematoma growth)
  • Most of the brain injury and swelling that happens after ICH is the result of inflammation caused by thrombin and other coagulation end-products


  • Determine if any predisposing illness – cancer, hypertension, smoking, trauma, dementia (amyloid), vascular malformations (aneurysm, AVM), anticoagulation (warfarin, heparin, LMWH), anti platelet medications, renal disease (uremic platelets), liver disease (abnormal coagulation parameters – prothrombin time), hematologic disease, recreational drug abuse (cocaine), seizure disorder, CVA, hemophilia, von Willebrand’s disease
  • History – sudden onset of focal neurological deficit, which progresses over minutes to hours, headache, vomiting
  • Physical examination
    • Vitals: elevated systolic blood pressure > 160 mm Hg, temperature > 37.5°C associated with growth of hematoma
    • HEENT: look for signs of injury (laceration, fracture, scars) on the head
    • Cardiovascular: rule out atrial fibrillation and other arrhythmias
    • CNS: detailed neurological exam-assess mental status, cranial nerves, sensory, motor, and cerebellar exam

++ ++

  • PT for patients on warfarin
  • PTT to rule out von Willebrand’s disease
  • Platelet count for thrombocytosis or thrombocytopenia
  • Liver function test, fibrinogen, D dimer,
  • Chemistry
  • Urine toxicology screen
  • Type and cross match sample


  • Imaging
    • Non-contrast computed tomography (CT) scan or magnetic resonance imaging (MRI) (whichever is faster to obtain) to assess:
      • Location of blood (deep, superficial, cerebellar, intraventricular)
      • Volume of blood ([A × B × C]/2)
      • Presence of hydrocephalus, midline shift
    • CT scan is better at evaluating ventricular extension
    • CT angiography for aneurysm, arteriovenous malformation
    • MRI is better at detecting underlying structural lesions and delineating perihematomal edema and herniation
  • ICP monitoring (see Chapter 98)
    • Especially helpful in patients with decreased level of consciousness


  • Emergency management
    • Airway evaluation for rapid neurological decline and necessity for endotracheal intubation
      • Failure to recognize leads to aspiration, hypoxemia, hypercapnia (with increased ICP and downward spiral)
      • For rapid sequence intubation, choose sedatives (propofol) and neuromuscular blockers (rocuronium; cisatracurium if indicated) that do not raise ICP. Consider topical lidocaine to suppress cough reflex
      • Avoid excessive hyperventilation to PCO2 below 28 mm Hg as it leads to increased vasoconstriction and brain ischemia
  • Blood pressure
    • Maintain SBP between 160 and 180 mm Hg or MAP < 130 mm Hg
      • Cardene        infusion, 5–15 mg/h or
      • Labetalol      5–20 mg bolus and infusion at 2 mg/h or
      • Esmolol        250 mcg/kg IV loading, maintenance at 25–300 mcg/kg/min
      • Avoid nitroprusside (can raise ICP)
    • Hypotension
      • Isotonic fluid bolus
      • Vasopressors (norepinephrine or phenylephrine) if needed to maintain a CPP of >60–80 mm Hg
  • Lowering ICP (See Chapter 98)
    • Head of bead >30°
    • Head midline
    • Sedation
    • ...

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