04/09/2025
Hypertension Intracranial Bleed (Hypertensive Intracerebral Hemorrhage – HICH)
This is one of the most serious complications of chronic, uncontrolled hypertension.
Let’s go step by step:
---
🔹 Definition
Intracranial hemorrhage (ICH) is bleeding into the brain parenchyma or ventricles due to rupture of cerebral vessels.
When caused by long-standing hypertension, it is called Hypertensive Intracerebral Hemorrhage (HICH).
---
🔹 Pathophysiology
Long-standing hypertension → lipohyalinosis and microaneurysm formation (Charcot–Bouchard aneurysms) in small penetrating arteries.
Commonly affected arteries:
Lenticulostriate arteries (branches of MCA)
Thalamoperforators
Pontine perforators
Cerebellar arteries
Vessel wall weakness → rupture → bleed → hematoma formation.
Expanding hematoma causes:
↑ Intracranial pressure (ICP)
Brain tissue compression
Herniation risk
Secondary ischemic injury around hematoma (perihematomal edema)
---
🔹 Common Sites of Bleeding
1. Basal ganglia (putamen, caudate) – most common (40–50%)
2. Thalamus
3. Pons (brainstem)
4. Cerebellum
5. Cerebral lobes (lobar ICH – less common in hypertension, more in amyloid angiopathy)
---
🔹 Risk Factors
Long-standing uncontrolled hypertension
Smoking, alcohol
Age > 50 years
CKD
Anticoagulant use (exacerbates bleeding)
Previous stroke
---
🔹 Clinical Features
Depends on location & size of bleed:
General Symptoms (due to ↑ ICP):
Sudden severe headache
Nausea, vomiting
Decreased consciousness, drowsiness → coma
Seizures (sometimes)
Focal Neurological Deficits:
Basal ganglia / thalamus → contralateral hemiplegia, hemisensory loss, gaze palsy
Cerebellum → ataxia, vertigo, vomiting, occipital headache, rapid deterioration due to brainstem compression
Pons → coma, quadriplegia, pinpoint pupils, abnormal respiration → very poor prognosis
Lobar → aphasia, neglect, seizures
---
🔹 Investigations
CT Head (Non-contrast) – investigation of choice
Shows hyperdense (white) bleed immediately
Hematoma size, location, mass effect, midline shift
MRI brain – useful for chronic bleed
Blood tests – CBC, coagulation profile, renal function
BP monitoring – persistent high values common
---
🔹 Complications
Raised intracranial pressure → herniation (uncal, tonsillar)
Hydrocephalus (if intraventricular extension)
Rebleeding
Neurological disability
Death
---
🔹 Management
Acute Management (Emergency)
1. Stabilization (ABC – airway, breathing, circulation)
Intubation if GCS ≤ 8
2. Blood Pressure control
Target: SBP 140–160 mmHg (not too low, as it may reduce cerebral perfusion)
IV labetalol, nicardipine, clevidipine preferred
Avoid rapid drop of BP
3. Reduce ICP
Elevate head 30°
Mannitol or hypertonic saline (if cerebral edema)
Control fever, avoid hyperglycemia
4. Reversal of anticoagulation if on warfarin/DOACs
5. Seizure control (levetiracetam/phenytoin if seizures)
6. Surgical management (in selected cases)
Cerebellar hematoma >3 cm with brainstem compression → surgical evacuation
Lobar superficial large hematoma with mass effect
Decompressive craniectomy in young patients
---
Long-Term Management
Strict BP control (lifestyle + antihypertensives)
Rehabilitation: physiotherapy, speech therapy
Prevention of recurrent stroke (manage risk factors: DM, cholesterol, smoking)
Regular follow-up with CT/MRI if needed
---
🔹 Prognosis
Mortality: ~30–50% within 30 days
Poor prognosis: brainstem bleed, large hematoma, intraventricular extension, low GCS
Survivors often left with neurological deficits
