TSH Hospital

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:

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🔹 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).

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🔹 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)

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🔹 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)

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🔹 Risk Factors

Long-standing uncontrolled hypertension

Smoking, alcohol

Age > 50 years

CKD

Anticoagulant use (exacerbates bleeding)

Previous stroke

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🔹 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

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🔹 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

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🔹 Complications

Raised intracranial pressure → herniation (uncal, tonsillar)

Hydrocephalus (if intraventricular extension)

Rebleeding

Neurological disability

Death

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🔹 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

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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

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🔹 Prognosis

Mortality: ~30–50% within 30 days

Poor prognosis: brainstem bleed, large hematoma, intraventricular extension, low GCS

Survivors often left with neurological deficits

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