This document discusses the medical and surgical management of intracerebral hemorrhage (ICH). ICH is defined as the acute extravasation of blood into the brain parenchyma from a ruptured blood vessel. Risk factors include age, hypertension, alcohol use, and coagulation disorders. Clinically, ICH presents with a sudden focal neurological deficit, headache, nausea, vomiting, decreased consciousness, and increased blood pressure. Rapid neuroimaging is recommended to distinguish ICH from ischemic stroke. Surgical evacuation of ICH may be considered for patients with decreased consciousness or elevated intracranial pressure refractory to medical management, but the benefits are unclear compared to medical management alone.

1. MANEJO MEDICO Y
QUIRURGICO

4.  HIC espontanea se define como la
extravasación aguda de sangre dentro del
parénquima cerebral secundaria a una rotura
vascular espontánea no traumática cuya
forma, tamaño y localización es muy variable.

5.  Su incidencia en Europa es de aproximadamente 15 casos
por cada 100.000 habitantes.
 La HIC sólo representa el 10-15% de todos los ictus;,
condicionada con un peor pronóstico, tasas más elevadas de
morbilidad y mortalidad.
 El 40,4% de todos los pacientes fallecen durante el primer
mes, la mayoría en los dos primeros días, y sólo un 20% son
independientes al cabo de 6 meses tras la HIC.
 La mortalidad a 30 días se correlaciona con el tamaño y la
localización de la HIC.
Van Asch CJ, Luitse MJ, Rinkel GJ, Van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral
haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9:167-76

6.  Primaria.
 Secundaria.
Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009;373:1632-44.

7. › Son factores mayores de riesgo:
-la edad, el sexo, la HTA y el alcohol, anticoagulacion.
-diabetes y el tabaco -factores de riesgo menor.
- Genéticos, como la mutación del gen que codifica la
subunidad α del factor XIII de la coagulación y la
angiopatía amiloidea.
 La HTA es el factor de riesgo más claramente implicado
en la HIC (55-81%)- hipertensor, y las alteraciones de la
coagulación -
 La HTA se encuentra en el 91% de los pacientes en el
momento de la hemorragia.
Belvis R, Cocho D, Marti-Fabregas J, Pagonabarraga J, Aleu A, Garcia-Bargo MD, et al. Benefits of a prehospital
stroke code system. Feasibility and efficacy in the first year of clinical practice in Barcelona, Spain. Cerebrovasc Dis.
2005;19:96-101.

14. CLÍNICA
 Déficit neurológico focal de inicio rápido,
 cefalea
 náuseas,
 vómitos(49%),
 disminución precoz del nivel de conciencia (50%)
 Aumento de la presión arterial (90%)
 Comienza habitualmente en vigilia.

27. © 2015 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.
Rapid neuroimaging with CT or MRI is recommended to
distinguish ischemic stroke from ICH
Class I, Level of
Evidence A
(Unchanged from the
previous guideline).
CT angiography and contrast-enhanced CT may be
considered to help identify patients at risk for
hematoma expansion
Class IIb, Level of
Evidence B
CT angiography, CT venography, contrast-enhanced
CT, contrast-enhanced MRI, MRA and MRV can be
useful to evaluate for underlying structural lesions
including vascular malformations and tumors when
there is clinical or radiologic suspicion
Class IIa, Level of
Evidence B (New
recommendation).

28. Ventricular drainage as treatment for hydrocephalus is
reasonable, especially in patients with decreased level
of consciousness
Class IIa; Level of
Evidence B (Revised
from the previous
guideline)
Patients with a GCS score of ≤8, those with clinical
evidence of transtentorial herniation, or those with
significant IVH or hydrocephalus might be considered
for ICP monitoring and treatment. A CPP of 50 to 70
mm Hg may be reasonable to maintain depending on
the status of cerebral autoregulation
Class IIb; Level of
Evidence
C. (Unchanged from the
previous guideline)
Corticosteroids should not be administered for
treatment of elevated ICP in ICH
Class III; Level of
Evidence B. (New
recommendation)
ICP Monitoring and Treatment: Recommendations

29. For most patients with supratentorial ICH, the usefulness
of surgery is not well established
Class IIb; Level of Evidence
A. (Revised from the previous
guideline)
A policy of early hematoma evacuation is not clearly
beneficial compared with hematoma evacuation when
patients deteriorate
Class IIb; Level of Evidence
A. (New recommendation)
Supratentorial hematoma evacuation in deteriorating
patients might be considered as a life-saving measure
Class IIb; Level of Evidence
C. (New recommendation)
© 2015 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

30. The effectiveness of minimally invasive clot evacuation
with stereotactic or endoscopic aspiration with or without
thrombolytic usage is uncertain
Class IIb; Level of Evidence
B. (Revised from the previous
guideline)
DC with or without hematoma evacuation might reduce
mortality for patients with supratentorial ICH who are in a
coma, have large hematomas with significant midline shift,
or have elevated ICP refractory to medical management
Class IIb; Level of Evidence
C.(New recommendation)
© 2015 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.