Intracerebral Hemorrhage

A 60-year-old comatose man was brought to the emergency department (ED). He had a history of diabetes, hypertension, and alcohol abuse. Relatives reported that the patient was noncompliant with his antihypertensive medication regimen.

Apparently, the patient was fine until a few hours before the sudden onset of a severe headache and vomiting followed by loss of consciousness. By the time the patient arrived at the hospital, he was deeply comatose.

His blood pressure in the ED was 210/180 mm Hg. A CT scan of the head revealed an acute right thalamic parenchyma hematoma that had ruptured into the ventricular system and the subarachnoid space.

Drs Arunabh and Manjula Thopcherla of North Shore University Hospital of Forest Hills, NY, write that intracerebral hemorrhage secondary to uncontrolled hypertension is one of the most common types of nontraumatic intracranial hemorrhage. Advanced age and heavy alcohol consumption increase the risk of these events.

The basal ganglia (putamen and globus pallidus), the thalamus, the cerebellum, and the pons are common sites of intracerebral hemorrhage. Most hypertensive hemorrhages develop over 30 to 90 minutes. CT is the diagnostic technique of choice to detect the site of hemorrhages.

Intracerebral hemorrhage has high morbidity and mortality. Supratentorial hemorrhages of more than 5 cm usually are fatal.

Treatment of severe hypertension is most important; however, be careful to avoid severe hypotension. Commonly used drugs include labetalol, enalapril, and hydralazine. Surgical evacuation of the hematoma is not helpful except in patients with cerebellar hematomas. Mannitol and other osmotic agents may be used to control intracranial pressure.

The optimal posthemorrhage outcome can be achieved with careful management of the patient's hypertension and good supportive care. This case demonstrates the importance of controlling high blood pressure, which is the leading cause of fatal intracerebral hemorrhages.

This patient was in a deep coma upon arrival in the ED; he was intubated and given intravenous labetalol. He died of a cerebral herniation after 2 days in the hospital.