Intracerebral hemorrhage (ICH) refers to bleeding within the brain parenchyma and accounts for 15%–30% of all strokes, with a high mortality rate. It most commonly occurs in hypertensive patients aged 50 and older, with a higher prevalence in men than in women. ICH often develops during activities and rarely during sleep, potentially due to elevated blood pressure. Approximately 50% of hemorrhages are located in the basal ganglia and may extend inward into the internal capsule. As the bleeding volume increases, hematoma formation damages brain tissue, while the mass effect from the hematoma and surrounding brain edema may lead to brain herniation. Hemorrhage within the brainstem or bleeding into the ventricles indicates a severe condition. The efficacy of surgical treatment for ICH remains a topic of debate.
Etiology
ICH is associated with hypertension, alcohol consumption, smoking, and liver dysfunction. Long-term use of anticoagulants such as aspirin increases the risk of ICH. Cerebral amyloid angiopathy (CAA), caused by pathological deposition of β-amyloid protein, accounts for approximately 10% of ICH cases. This condition primarily affects the small meningeal or cortical vessels, particularly in the white matter, but does not cause hemorrhages in the basal ganglia or brainstem.
Diagnosis
Patients with a history of hypertension and arteriosclerosis who experience sudden, severe headache, vomiting, and varying degrees of altered consciousness, often accompanied by neurological deficits such as hemiplegia or aphasia, require timely head CT examination to differentiate between ICH and cerebral infarction. Head CT imaging can rapidly and accurately locate acute hemorrhages, which appear as high-density lesions. Hemorrhages may rupture into the ventricles or cause concurrent hydrocephalus. MRI is not the preferred initial diagnostic tool but can aid in diagnosing cerebral amyloid angiopathy in later stages.
Patients aged 60 or older with intracortical or subcortical lobe hemorrhages and no apparent cause for bleeding should be evaluated for CAA. Pathological examination of cerebral vascular tissue is required for a definitive diagnosis.
Surgical Treatment
The primary goal of surgery is to remove the hematoma, stop the bleeding, and alleviate the mass effect caused by the hematoma and brain edema. However, surgical removal of hematomas does not generally improve neurological deficits.
Indications for Surgery
The decision to perform surgery depends on factors such as the patient’s age, neurological function, location and volume of the hemorrhage, and treatment goals expressed by the patient’s family. Hematoma removal is considered in cases where:
- The hematoma and surrounding edema create a significant mass effect, resulting in symptoms such as hemiplegia, aphasia, confusion, or agitation, with CT imaging showing midline shift and early signs of brain herniation.
- Hemorrhage is located in the cortical (non-deep) areas of the cerebral hemisphere and in the non-dominant hemisphere, with a moderate hematoma volume (10–30 ml). Hematomas smaller than 10 ml typically do not require surgery. Large hematomas (>30 ml) are associated with poor outcomes, and massive hemorrhages (>60 ml) with Glasgow Coma Scale (GCS) scores ≤8 carry a 30-day mortality rate of 91%. Cerebellar hemorrhages with GCS ≤13 and hematoma diameter ≥4 cm are also candidates for surgical removal.
Contraindications for Surgery
Surgery is not advised for elderly patients or those with severe systemic conditions such as diabetes or significant cardiac, pulmonary, hepatic, or renal dysfunction. Other contraindications include:
- Large volume hemorrhages in deep brain regions of the dominant hemisphere.
- Profound coma (GCS ≤5).
- Severe neurological impairment or loss of brainstem function (e.g., fixed gaze, decerebrate rigidity).
Surgical Considerations
Neuroendoscopy, minimally invasive craniotomy, or CT-guided puncture with hematoma aspiration can be employed. The use of urokinase within the hematoma cavity may assist in clot dissolution.
During surgery, samples of the hematoma, abnormal vascular structures (if present), and, if feasible, the wall of the hematoma cavity should be collected for pathological analysis to exclude tumors, arteriovenous malformations, or cerebral amyloid angiopathy.
Brain herniation remains the leading cause of death, with most instances occurring within the first week in patients with GCS ≤7. Mortality rates vary significantly depending on the size and location of the hematoma, the patient’s age and underlying conditions, and the cause of hemorrhage. Lobar hemorrhages generally have better prognoses compared to deeper hemorrhages in areas such as the basal ganglia or brainstem.