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Cerebral Hemorrhage: Causes, Symptoms, and Emergency Response

Cerebral hemorrhage (intracerebral hemorrhage, ICH) is bleeding within the brain parenchyma from a ruptured blood vessel. It accounts for 10–15% of strokes but carries high mortality and disability.

Major Causes

  • Hypertension (chronic, uncontrolled): #1 cause. Lipohyalinosis → microaneurysms (Charcot-Bouchard) in deep perforators (basal ganglia, thalamus, pons, cerebellum).
  • Cerebral Amyloid Angiopathy (CAA): Amyloid-β in cortical vessels → lobar hemorrhages in elderly.
  • Anticoagulation/Antiplatelets: Warfarin, DOACs, dual antiplatelet → increased bleed risk/expansion.
  • Vascular Malformations: AVM, cavernoma, aneurysm.
  • Drugs: Cocaine, amphetamines (vasospasm + BP surge).
  • Tumor: Hemorrhagic metastasis, glioblastoma.
  • Trauma: Contusion, delayed traumatic ICH.
  • Coagulopathy: Thrombocytopenia, hemophilia, liver disease.

Clinical Presentation

  • Sudden onset (seconds–minutes): Severe headache ("thunderclap" if SAH), focal deficit.
  • Focal signs: Hemiparesis, hemisensory loss, gaze deviation, aphasia (dominant hemisphere), ataxia (cerebellar).
  • Depressed consciousness: GCS decline, coma if large/expanding.
  • Nausea/vomiting: Increased ICP.
  • Seizures: At onset or delayed (cortical irritation).

Emergency Response

  1. Call 911 immediately. Time = brain.
  2. Do not give aspirin, anticoagulants, or food/drink.
  3. Position: Head elevated 30° if conscious; recovery position if unconscious.
  4. EMS: Prehospital stroke scale (Cincinnati, FAST), prenotify stroke center.

Hospital Management

  • CT Head (non-contrast): Diagnoses ICH, locates bleed, estimates volume (ABC/2 method).
  • CTA/CTV: Spot sign (active extravasation), vascular malformation.
  • BP Target: SBP < 140 mmHg (INTERACT2/ATACH-2) – rapid reduction < 1 hour.
  • Reversal: PCC + vitamin K (warfarin), andexanet alfa (factor Xa inhibitors), idarucizumab (dabigatran).
  • Surgery: Decompressive craniectomy, hematoma evacuation (MISTIE III, ENRICH trials—select cases).
  • ICU monitoring: ICP, EEG, repeated imaging.

Prognosis

  • 30-day mortality: ~35–40%.
  • Functional independence at 90 days: ~20%.
  • Predictors: Volume > 30 mL, GCS < 8, IVH, age > 80, infratentorial location.

FAST + Sudden Severe Headache = Think Hemorrhage. Activate EMS.

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