Intracerebral and Subarachnoid Hemorrhage

Abstract

Approximately 15 % of all strokes are hemorrhagic [1]. Intracerebral hemorrhage (ICH) is one of the most devastating forms of stroke. The mortality rate in the first 30 days after ICH is 40 % with more than half of the deaths occurring in the first 2 days; only 12–39 % of patients achieve functional independence [1]. The incidence of ICH increases with age and is more common in Asians than Caucasians or blacks. Clot volume at presentation is the most powerful predictor of outcome. Clot volume can be measured using computer algorithms available in some CT scanners or it can be approximated by the ellipsoid method [2]: ellipsoid volume = (AP × LAT × HT)/2. Generally a good functional outcome is associated with a hematoma volume of less than 30 mL [3–8]. Other important variables are clot expansion, patient age, baseline neurologic status, site of hemorrhage and intraventricular hemorrhage volume. Basal ganglia bleeds generally have the best prognosis followed by lobar hemorrhages; patients with pontine and brain stem bleeds have the worst prognosis [3, 6]. The most common sites of ICH are listed in Table 43.1. In patients who present within 3 h of symptom onset, 26 % of hematomas expand more than 33 % over the first hour, and another 12 % expand this amount over the next 20 h [9, 10]. In warfarin-associated ICH up to 50 % of patients develop hematoma expansion [11]. A number of prognostic scoring systems have been developed to risk stratify patients with ICH [5, 8, 12]. The modified ICH prognostic score and the Functional Risk Stratification Score (FUNC) are based on hematoma volume, age GCS, hematoma location intraventricular hemorrhage and pre-morbid cognitive status (see Table 43.2) [4, 7]. The STITCH investigators have developed a prognostic score based on the GCS at presentation, the patients’ age and hematoma volume: 10 × GCS − (age − 0.64 × volume). A score of 27.67 discotomizes patients into a poor and good prognostic group [13–15].