Clinical Review

Spontaneous intracerebral haemorrhage

BMJ 2009; 339 doi: (Published 24 July 2009) Cite this as: BMJ 2009;339:b2586
  1. Rustam Al-Shahi Salman, MRC clinician scientist and honorary consultant neurologist1,
  2. Daniel L Labovitz, assistant professor2,
  3. Christian Stapf, assistant professor of neurology3
  1. 1Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU
  2. 2NYU Medical Center, Schwartz Health Care Center, Suite 5F, 530 First Avenue, New York, NY 10016, USA
  3. 3Stroke Unit, Service de Neurologie, Hôpital Lariboisière—APHP, 2 Rue Ambroise Paré, 75475 Paris cedex 10, France
  1. Correspondence to: R Al-Shahi Salman Rustam.Al-Shahi{at}

    Spontaneous (non-traumatic) intracerebral haemorrhage accounts for at least 10% of all strokes in the United Kingdom,1 but the incidence is higher in some ethnic groups.w1 Intracerebral haemorrhage may present with a sudden focal neurological deficit or a reduced level of consciousness, after which it kills about half of those affected within one month and leaves most survivors disabled.2

    Although early case fatality after spontaneous intracerebral haemorrhage has not changed over the past two decades,1 2 brain imaging has illuminated the pathophysiology of intracerebral haemorrhage and its various causes,3 w2 such that the term primary intracerebral haemorrhage now seems antiquated. Improving prevention of intracerebral haemorrhage in primary care and its outcome in secondary care is especially important in view of trends towards a rising incidence of intracerebral haemorrhage in an ageing population.1

    How should intracerebral haemorrhage be distinguished from other causes of stroke?

    No clinical scoring system has been shown to reliably differentiate intracerebral haemorrhage from ischaemic stroke.w3 Timely brain imaging is the key to recognising intracerebral haemorrhage. Computed tomography detects symptomatic intracerebral haemorrhage within minutes of symptom onset and up to one week thereafter; magnetic resonance imaging with gradient-recalled echo sequences reliably differentiates infarction from haemorrhage more than one week after onset of stroke.4 Diagnostic imaging distinguishes intracerebral haemorrhage from other types of intracranial haemorrhage (fig 1), although intracerebral haemorrhage may extend into other intracranial compartments. This distinction is important, because the causes, prognosis, and treatment vary according to the location of intracranial haemorrhage.5

    Fig 1 Axial illustration of the brain showing the subtypes of intracranial haemorrhage

    What are the detectable causes of intracerebral haemorrhage?

    The major risk factors for spontaneous intracerebral haemorrhage are systemic arterial hypertension, excess alcohol consumption, male sex, increasing age, and smoking.6 w4 w5 These risk factors may lead to secondary vascular changes, such as small vessel disease and arterial aneurysms, which may eventually …

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