Diagnóstico y tratamiento de la hemorragia intracerebral

Abstract

Intracerebral hemorrhage (ICH) is the main hypertensive mechanism occurring as the consequence of structural changes in the small perforating vessels of the cerebral hemispheres and brain stem. These vascular lesions cause deeply situated hemorrhages in the cerebral hemispheres (basal grey nuclei and thalamus) and brain stem (pons); less common sites are in the subcortical white matter and cerebellum. There are many non-hypertensive causes of ICH including: amyloid cerebral angiopathy, vascular malformations, intracranial tumours, the use of anticoagulant and fibrinolytic agents, sympthomimetic drugs and vasculitis. These conditions usually cause hemorrhages situated in the subcortical white matter (lobar), some predominantly in the elderly (amyloid cerebral angiopathy) and others mainly in the young (vascular malformations and consumption of sympathomimetic drugs). Radiological diagnosis of ICH is easily made on computerized tomography (CT), and magnetic resonance (MR) gives additional data such as the stage of evolution of the hemorrhage and its possible causes (vascular malformations, underlying tumours). The therapeutic managements of ICH includes: immediate emergency treatment (the need for endotracheal intubation, control of the blood pressure) and the management of the conditions causing ICH (coagulation disorders, detection of toxic substances such as cocaine and other sympathomimetic agents); treatment of intracranial hypertension (hyperventilation, osmotic diuretics, barbiturate coma); the decision to proceed to surgery (reserved for patients with cerebellar bleeding accompanied by supratentorial hydrocephalus, lobar hemorrhage of intermediate size together with progressive neurological deterioration and signs of a space occupying lesion on CT, and ventriculostomy for thalamic or caudate nucleus bleeding with hydrocephalus.