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Chapter 12 - Intracerebral Hemorrhage

from Section 3 - Diagnostics and Syndromes

Published online by Cambridge University Press:  16 May 2019

By
Corina Epple ,
Michael Brainin  and
Thorsten Steiner
Edited by
Michael Brainin  and
Wolf-Dieter Heiss
Michael Brainin
Affiliation:
Donau-Universität Krems, Austria
Wolf-Dieter Heiss
Affiliation:
Universität zu Köln
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Textbook of Stroke Medicine , pp. 213 - 232
Publisher: Cambridge University Press
Print publication year: 2019

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References

Sacco, S, Marini, C, Toni, D, Olivieri, L, Carolei, A. Incidence and 10 year survival of intracerebral hemorrhage in a population-based registry. Stroke 2009; 40: 394–9.Google Scholar
Fang, J, Alderman, MH, Keenan, NL, Croft, JB. Declining US stroke hospitalization since 1997: national hospital discharge survey, 1988–2004. Neuroepidemiology 2007; 29: 243–9.CrossRefGoogle ScholarPubMed
Islam, MS, Anderson, CS, Hankey, GJ, et al. Trends in incidence and outcome of stroke in Perth, Western Australia during 1989 to 2001: the Perth Community Stroke Study. Stroke 2008; 39: 776–82.CrossRefGoogle ScholarPubMed
Sacco, RL, Boden-Albala, B, Gan, R, et al. Stroke incidence among white, black, and hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol 1998; 147: 259–68.Google Scholar
Knudsen, KA, Rosand, J, Karluk, D, Greenberg, SM. Clinical diagnosis of cerebral amyloid angiopathy: validation of the Boston criteria. Neurology 2001; 56: 537–9.Google Scholar
Lang, EW, Ren, Ya Z, Preul, C, et al. Stroke pattern interpretation: the variability of hypertensive versus amyloid angiopathy hemorrhage. Cerebrovasc Dis 2001; 12: 121–30.Google Scholar
Chiquete, E, Broderick, J, Hennerici, M. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neuology 2006; 66: 1175–81.Google Scholar
Ruiz-Sandoval, JL, Romero-Vargas, S, Chiquete, E. Hypertensive intracerebral hemorrhage in young people: previously unnoticed age-related clinical differences. Stroke 2006; 37: 2946–50.CrossRefGoogle ScholarPubMed
Broderick, J, Brott, T, Duldner, JE, Tomsick, T, Huster, G. Volume of intracrerbral hemorrhage: a powerful and easy-to-use predictor of 30-day mortality. Stroke 1993; 24: 987–93.CrossRefGoogle Scholar
Counsell, C, Boonyakarnkul, S, Dennis, M, et al. Primary intracerebral haemorrhage in the Oxfordshire Community Stroke Project, 2: prognosis. Cerebrovasc Dis 1995; 5: 26–34.CrossRefGoogle Scholar
Fujii, Y, Takeuchi, S, Sasaki, O, Minakawa, T, Tanaka, R. Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage. Stroke 1998; 29: 1160–6.CrossRefGoogle ScholarPubMed
Hemphill, JC, Bonovich, DC, Besmertis, L, Manley, GT, Johnston, SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32: 891–7.Google Scholar
Tuhrim, S, Horowitz, DR, Sacher, M, Godbold, JH. Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med 1999; 27: 617–21.Google Scholar
Steiner, T, Schneider, D, Mayer, S, et al. Dynamics of intraventricular hemorrhage in patients with spontaneous intracerebral hemorrhage: risk factors, clinical impact, and effect of hemostatic therapy with recombinant activated factor VII. Neurosurgery 2006; 59: 767–74.CrossRefGoogle ScholarPubMed
Diringer, MN, Edwards, DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 2001; 29: 635–40.CrossRefGoogle ScholarPubMed
Rønning, OM, Guldvog, B, Stavem, K. The benefit of an acute stroke unit in patients with intracranial haemorrhage: a controlled trial. J Neurol Neurosurg Psychiatry 2001; 70: 631–4.Google Scholar
Paolucci, S, Antonucci, G, Grasso, MG, et al. Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison. Stroke 2003; 34: 2861–5.Google Scholar
Leira, R, Davalos, A, Silva, Y, et al. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology 2004; 63: 461–7.Google Scholar
Davis, SM, Broderick, J, Hennerici, M, et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 2006; 66: 1175–81.CrossRefGoogle ScholarPubMed
Martini, SR, Flaherty, ML, Brown, AM, et al. Risk factors for intracerebral hemorrhage differ according to hemorrhage location. N Engl J Med 2012; 79: 2275–82.Google Scholar
Rost, NS, Greenberg, SM, Rosand, J. The genetic architecture of intracerebral hemorrhage. Stroke 2008; 39: 2166–73.Google Scholar
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033–41.Google Scholar
Kurth, T, Kase, CS, Berger, K, et al. Smoking and risk of hemorrhagic stroke in women. Stroke 2003; 34: 2792–5.Google Scholar
Kurth, T, Kase, CS, Berger, K, et al. Smoking and the risk of hemorrhagic stroke in men. Stroke 2003; 34: 1151–5.Google ScholarPubMed
Juvela, S, Hillbom, M, Palomaki, H. Risk factors for spontaneous intracerebral hemorrhage. Stroke 1995; 26: 1558–64.Google Scholar
Casolla, B, Dequatre-Ponchelle, N, Rossi, C. Heavy alcohol intake and intracerebral hemorrhage: characteristics and effect on outcome. Neuology 2012; 79: 1109–15.Google Scholar
Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355: 549–59.Google Scholar
Fitzmaurice, E, Wendell, L, Snider, R, et al. Effect of statins on intracerebral hemorrhage outcome and recurrence. Stroke 2008; 39: 2151–4.Google Scholar
Westover, MB, Bianchi, MT, Eckman, MH, Greenberg, SM. Statin use following intracerebral hemorrhage: a decision analysis. Arch Neurol 2011; 68: 573–9.Google Scholar
He, J, Whelton, PK, Vu, B, Klag, MJ. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. JAMA 1998; 280: 1930–5.Google Scholar
Kase, CS, Mohr, JP, Caplan, LR. Intracerebral hemorrhage. In: Mohr, JP, Choi, DW, Grotta, JC, et al., eds. Stroke: Pathophysiology, Diagnosis, and Management. 4th edn. New York: Churchill Livingstone; 2004: 327–76.Google Scholar
Rosand, J, Hylek, EM, O'Donnell, HC, Greenberg, SM. Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study. Neurology 2000; 55: 947–51.CrossRefGoogle ScholarPubMed
Flaherty, ML, Kissela, B, Woo, D, et al. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology 2007; 68: 116–21.Google Scholar
Flibotte, JJ, Hagan, N, O'Donnell, J, Greenberg, SM, Rosand, J. Warfarin, hematoma expansion and outcome of intracerebral hemorrhage. Neurology 2004; 63: 1059–64.Google Scholar
Hart, RG, Boop, BS, Anderson, DC. Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke 1995; 26: 1471–7.Google Scholar
Greenberg, SM, Briggs, ME, Hyman, BT, et al. Apolipoprotein E epsilon 4 is associated with the presence and earlier onset of hemorrhage in cerebral amyloid angiopathy. Stroke 1996; 27: 1333–7.Google Scholar
McCarron, MO, Nicoll, JA. Apolipoprotein E genotype and cerebral amyloid angiopathy-related hemorrhage. Ann NY Acad Sci 2000; 903: 176–9.Google Scholar
Becker, K, Tirschwell, D. Intraparenchymal hemorrhage, bleeding, hemostasis, and the utility of CT angiography. Int J Stroke 2008; 3: 11–13.Google Scholar
Kidwell, CS, Wintermark, M. Imaging of intracranial haemorrhage. Lancet Neurol 2008; 7: 256–67.Google Scholar
Steiner, T, Kaste, M, Forsting, M, et al. Recommendations for the management of intracranial haemorrhage – part 1: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis 2006; 22: 294–316.Google Scholar
Delgado Almandoz, JE, Yoo, AJ, Stone, MJ, et al. Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: the spot sign score. Stroke 2009; 40: 2994–3000.Google Scholar
Goldstein, JN, Fazen, LE, Snider, R, et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 2007; 68: 889–94.Google Scholar
Li, N, Wang, Y, Wang, W, et al. Contrast extravasation on computed tomography angiography predicts clinical outcome in primary intracerebral hemorrhage, a prospective study of 139 cases. Stroke 2011; 42: 3441–6.Google Scholar
Demchuk, AM, Dowlatshahi, D, Rodriguez-Luna, D, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (predict): a prospective observational study. Lancet Neurol 2012; 11: 307–14.Google Scholar
Fazekas, F, Kleinert, R, Roob, G, et al. Histopathologic analysis of foci of signal loss on gradient-echo T2*-weighted MR images in patients with spontaneous intracerebral hemorrhage: evidence of microangiopathy-related microbleeds. Am J Neuroradiol 1999; 20: 637–42.Google Scholar
Cordonnier, C, Al-Shahi Salman, R, Wardlaw, J. Spontaneous brain microbleeds: systematic review, subgroup analyses and standards for study design and reporting. Brain 2007; 130: 1988–2003.Google Scholar
Kinoshita, T, Okudera, T, Tamura, H, Ogawa, T, Hatazawa, J. Assessment of lacunar hemorrhage associated with hypertensive stroke by echo-planar gradient-echo T2*-weighted MRI. Stroke 2000; 31: 1646–50.Google Scholar
Tsushima, Y, Aoki, J, Endo, K. Brain microhemorrhages detected on T2*-weighted gradient-echo MR images. Am J Neuroradiol 2003; 24: 88–96.Google Scholar
Tsushima, Y, Tamura, T, Unno, Y, Kusano, S, Endo, K. Multifocal low-signal brain lesions on T2*-weighted gradient-echo imaging. Neuroradiology 2000; 42: 499–504.CrossRefGoogle ScholarPubMed
Kidwell, CS, Saver, JL, Villablanca, JP. Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application. Stroke 2002; 33: 95–8.Google Scholar
Wong, KS, Chan, YL, Liu, JY, Gao, S, Lam, WW. Asymptomatic microbleeds as a risk factor for aspirin-associated intracerebral hemorrhages. Neurology 2003; 60: 511–13.Google Scholar
Fiehler, J, Albers, GW, Boulanger, JM. Bleeding risk analysis in stroke imaging before thrombolysis (Brasil): pooled analysis of T2*-weighted magnetic resonance imaging data from 570 patients. Stroke 2007; 38: 2738–44.Google Scholar
Kakuda, W, Thijs, VN, Lansberg, MG. Clinical importance of microbleeds in patients receiving IV thrombolysis. Neurology 2005; 65: 1175–8.Google Scholar
Greenberg, SM, Eng, JA, Ning, M, Smith, EE, Rosand, J. Hemorrhage burden predicts recurrent intracerebral hemorrhage after lobar hemorrhage. Stroke 2004; 35: 1415–20.Google Scholar
Weir, CJ, Murray, GD, Adams, FG, et al. Poor accuracy of stroke scoring systems for differential clinical diagnosis of intracranial haemorrhage and infarction. Lancet 1994; 344: 999–1002.Google Scholar
Herbstein, DJ, Schaumberg, HH. Hypertensive intracerebral hematoma. An investigation of the initial hemorrhage and rebleeding using chronium CR 51-labeled erythrocytes. Arch Neurol 1974; 30: 412–14.Google Scholar
Xi, G. Intracerebral hemorrhage: pathophysiology and therapy. Neurocrit Care 2004; 1: 5–18.Google Scholar
Brott, T, Broderick, J, Kothari, R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997; 28: 1–5.Google Scholar
Gebel, JM, Jr., Jauch, EC, Brott, TG, et al. Relative edema volume is a predictor of outcome in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke 2002; 33: 2636–41.Google Scholar
Castillo, J, Davalos, A, Alvarez-Sabin, J, et al. Molecular signatures of brain injury after intracerebral hemorrhage. Neurology 2002; 58: 624–9.Google Scholar
Lee, KR, Colon, GP, Betz, AL, et al. Edema from intracerebral hemorrhage: the role of thrombin. J Neurosurg 1996; 84: 91–6.Google Scholar
Sansing, LH, Kaznatcheeva, EA, Perkins, CJ, et al. Edema after intracerebral hemorrhage: correlations with coagulation parameters and treatment. J Neurosurg 2003; 98: 985–92.Google Scholar
Schellinger, PD, Fiebach, JB, Hoffmann, K, et al. Stroke MRI in intracerebral hemorrhage: is there a perihemorrhagic penumbra? Stroke 2003; 34: 1674–9.Google Scholar
Mendelow, AD, Gregson, B, Fernandes, HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral haemorrhage (STICH): a randomised trial. Lancet 2005; 365: 387–97.CrossRefGoogle Scholar
Mendelow, AD, Gregson, B, Mitchell, P, et al. Surgical trial in lobar intracerebral haemorrhage (STICH II) protocol. Trials 2011; 12: 124.Google Scholar
Gregson, BA, Broderick, JP, Auer, LM, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke 2012; 43: 1496–504.Google Scholar
Lampl, Y, Ronit, G, Eshel, T. Neurological and functional outcome in patients with supratentorial hemorrhages. A prospective study. Stroke 1995; 26: 2249–53.Google Scholar
Staykov, D, Huttner, HB, Struffert, T, et al. Intraventricular fibrinolysis and lumbar drainage for ventricular hemorrhage. Stroke 2009; 40: 3275–80.Google Scholar
Hanley, DF, Lane, K, McBee, N, et al. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389: 603–11.Google Scholar
Staykov, D, Kuramatsu, JB, Bardutzky, J, et al. Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: a randomized trial and individual patient data meta-analysis. Ann Neurol 2017; 81: 93–103.CrossRefGoogle ScholarPubMed
Hanley, DF, Thompson, RE, Muschelli, J, et al. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 2016; 15: 1228–37.Google Scholar
Steiner, T, Al-Shahi Salman, R, Beer, R, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9: 840–55.Google Scholar
Anderson, CS, Huang, Y, Wang, JG, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol 2008; 7: 391–9.Google Scholar
Qureshi, AI, Tariq, N, Divani, AA, et al. Antihypertensive treatment of acute cerebral hemorrhage (ATACH). Crit Care Med 2010; 38: 637–48.Google Scholar
Morgenstern, LB, Hemphill, JC 3rd, Anderson, C, et al. Nursing at AHASCaCoC. Guidelines for the management of spontaneus intracerebral hemorrhage: a guidline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 41: 2108–29.Google Scholar
Ohwaki, K, Yano, E, Nagashima, H, et al. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke 2004; 35: 1364–7.Google Scholar
Qureshi, AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation 2008; 118: 176–87.CrossRefGoogle ScholarPubMed
Broderick, JP, Connolly, ES, Feldman, E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. 2007 update. A guideline from the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007; 38: e391–413.CrossRefGoogle ScholarPubMed
Diedler, J, Sykora, M, Rupp, A, et al. Impaired cerebral vasomotor activity in spontaneous intracerebral hemorrhage. Stroke 2009; 40: 815–19.Google Scholar
Hemphill, JC 3rd, Greenberg, SM, Anderson, CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46: 2032–60.Google Scholar
Anderson, C, Heeley, E, Huang, Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage (INTERACT 2). N Engl J Med 2013; 368: 2355–65.Google Scholar
Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators. Antihypertensive treatment of acute cerebral hemorrhage. Crit Care Med 2010; 38: 637–48.Google Scholar
Qureshi, AI, Palesch, YY, Barsan, WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375: 1033–43.Google Scholar
Al-Shahi Salman, R. Haemostatic drug therapies for acute spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2009: CD005951.Google Scholar
Yuan, ZH, Jiang, JK, Huang, WD, et al. A meta-analysis of the efficacy and safety of recombinant activated factor VII for patients with acute intracerebral hemorrhage without hemophilia. J Clin Neurosci 2010; 17: 685–93.CrossRefGoogle ScholarPubMed
Sprigg, N, Renton, CJ, Dineen, RA, Kwong, Y, Bath, PM. Tranexamic acid for spontaneous intracerebral hemorrhage: a randomized controlled pilot trial (isrctn50867461). J Stroke Cerebrovasc Dis 2014; 23: 1312–18.Google Scholar
Baharoglu, MI, Cordonnier, C, Al-Shahi Salman, R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016; 387: 2605–13.Google Scholar
Aguilar, MI, Hart, RG, Kase, CS, et al. Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion. Mayo Clin Proc 2007; 82: 82–92.Google Scholar
Kuramatsu, JB, Gerner, ST, Schellinger, PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313: 824–36.Google Scholar
Huttner, HB, Schellinger, PD, Hartmann, M, et al. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy. Comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke 2006; 37: 1465–70.Google Scholar
Steiner, T, Poli, S, Griebe, M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol 2016; 15: 566–73.Google Scholar
Eerenberg, ES, Kamphuisen, PW, Sijpkens, MK, Meijers, JC, Buller, HR. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 2011; 124: 1573–9.Google Scholar
Steiner, T, Bohm, M, Dichgans, M, et al. Recommendations for the emergency management of complications associated with new direct oral anticoagulants (DOAC) apixaban, dabigatran, and rivaroxaban. Clin Res Cardiol 2013; 102: 399–412.Google Scholar
Purrucker, JC, Haas, K, Rizos, T, et al. Early clinical and radiological course, management, and outcome of intracerebral hemorrhage related to new oral anticoagulants. JAMA Neurol 2016; 73: 169–77.Google Scholar
Pollack, CV, Jr., Reilly, PA, van Ryn, J, et al. Idarucizumab for dabigatran reversal – full cohort analysis. N Engl J Med 2017; 377: 431–41.Google Scholar
Siegal, DM, Curnutte, JT, Connolly, SJ, et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med 2015; 373: 2413–24.Google Scholar
Leissinger, CA, Blatt, PM, Hoots, WK, Ewenstein, B. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol 2008; 83: 137–43.Google Scholar
van Ryn, J, Stangier, J, Haertter, S, et al. Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010; 103: 1116–27.Google Scholar
Wagner, F, Peters, H, Formella, S, et al. Effective elimination of dabigatran with haemodialysis: a phase I single-centre study in patients with end stage renal disease. American Heart Association Scientific Sessions November 13–15, 2011 (Orlando, Florida).Google Scholar
Osborn, AG, Salzman, KL, Barkovich, AJ. Diagnostic Imaging: Brain. 2nd edn. London: Lippincott Williams & Wilkins; 2010.Google Scholar

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