Haemorrhagic Stroke-

Faced with a patient with ICH, the mortality is related to the age of the patient, co-morbidity, clinical condition of the patient, the size and the location of the clot. It is crucial to evaluate and investigate for an underlying cause such as hypertension, arteriovenous malformation, intracranial aneurysms, blood dyscrasias, anticoagulation, chronic alcoholism, vasculitis and possibly tumors.

The ICH can occur in any lobe of the brain but it is most common in the deep white matter tracts, in the basal ganglia and the thalamus. See another ICH below. This clot is also of a large side in the right hemisphere. There is significant brain shift to the left.

• Adequate oxygenation should be maintained
• Correct hypotension/hypovolemia with colloids or blood transfusion.
• Hypertension should be very carefully treated and only decreased maginally otherwise ischemia and brain infarction may be the result. Prevent hypotension
• If hypertension is due to raised intracranial pressure from a large ICH, it should be treated actively by surgical evacuation. If due to oedema, medical treatment with Mannitol and or ventilation is preferred.

• In general, patients with small volume clots <25mls are best left to medical treatment and
• Patients with large clots >50mls should be considered for surgical evacuation.
• There are cases of massive clots >85mls who will probably do badly regardless of method of management.
• The age, GCS and comorbid factors will influence decisions in such cases.
• Deep putaminal clots are often not evacuated, as even if saved, surgery leaves such patients severely disabled.
• The presence of subcortical , cerebellar clots is associated with better surgical outcome.

Large fatal ICH and on the right a smaller basal ganglia clot. Both may not need operation

The survival rate of patients with ICH treated medically is low. Only 10% will be alive in 5 years. Surgically treated patients fair only slightly better. The operative rate in a Scottish study was 32% with a 27% mortality.

Overall, almost half of the patients will die and a further half of the survivors will be severely disabled. In the report by Juvela (1995), on 156 consecutive patients with ICH, 41% were independent at 1 year, 22% were disabled and 37% had died. The significant predictors of death were GCS on admission (p<0.001) and the presence of subcortical hematoma (p<0.05, inverse relationship).

Whatever therapy is preferred, do remember that there is further morbidity and mortality related to hospitalisation especially in the older patient and the alcoholic. Bed-rest can be dangerous with aspiration, pneumonia, deep vein thrombosis, hypoxia, anemia and bed sores as important causes of death.

Controversial issues

• Age and ICH
• Cerebellar ICH
• Hypothermia and hyperbaric oxygen in patient management

Must read Essays

• Fernandes H M, Mendelow A D. Spontaneous intracerebral haemorrhage: a surgical dilemma. British Journal of Neurosurgery 1999;13(4):389-394.
• Morgenstern L B, Frankowski R F, Shedden P, Pasteur W, Grotta J C. Surgical treatment for intracerebral hemorrhage (STICH). A single-center, randomized clinical trial. Neurology 1998;51:1359-1363
• Schwarz S, Jauss M, Krieger D, Dorfler A, Albert F, Hacke W. Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: a case-control study. Acta Neurochirurgica 1997;139(10):897-903