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Classification of Intracerebral Haemorrhages
Renan Domingues, 1,4 Costanza Rossi 2 and Charlotte Cordonnier 3
1. Neurologist and Professor; 2. Neurologist; 3. Neurologist and Professor, Department of Neurology, University of Lille Nord de France, UDSL, CHU Lille, EA 1046,
Lille, France; 4. Neurologist and Professor, CAPES Foundation, Ministry of Education, Brasilia-DF, Brazil
Abstract Spontaneous intracerebral haemorrhage (ICH) is defined as a collection of blood in the cerebral parenchyma that is not caused by trauma.
ICH is the second most frequent cause of stroke, accounting for 10–15 % of all cases in high-income countries and about 20 % in low- to
middle-income countries. Despite an apparent stability of incidence over the past decades, the profile of ICH has changed: there are fewer
deep ICHs associated with pre-stroke hypertension, whereas the increasing age of the population associated with a more extensive use of
antithrombotic drugs leads to an increase of lobar ICH. Deep perforating vasculopathy remains the most important cause of ICH, followed
by cerebral amyloid angiopathy, these two aetiologies account for nearly 70 % of all ICH cases. Recent scientific evidence has highlighted
new aspects of the pathophysiology of such disorders; nevertheless, the morbidity and mortality of ICH remain extremely high. In the
present article, the different causes of ICH will be reviewed.
Keywords Intracerebral haemorrhage (ICH), deep perforating vasculopathy, cerebral amyloid angiopathy (CAA), cerebral microbleeds (CMBs), brain
intracranial vascular malformations, haemorrhagic transformation
Disclosure: Renan Domingues has no conflicts of interest to declare. Costanza Rossi was an investigator in Brainsgate (Impact-24), Astra-Zeneca (SOCRATES), Pfizer
(A9951024). No personal funding, all honoraria were paid to Adrinoid or Lille University Hospital. Charlotte Cordonnier was investigator in Photothera (NEST3), Brainsgate
(Impact-24), Astra-Zeneca (SOCRATES). She is principal investigator in France for Pfizer (A9951024). She received speaker fees from Bayer, BMS. No personal funding, all
honoraria were paid to Adrinoid or Lille University Hospital. No funding was received for the publication of this article.
Received: 17 May 2014 Accepted: 3 October 2014 Citation: European Neurological Review, 2014;9(2):129–35
Correspondence: Charlotte Cordonnier, Department of Neurology & Stroke Unit , EA 1046, Lille University Hospital, 59037 cedex, Lille, France.
Spontaneous intracerebral haemorrhage (ICH) is defined as a focal
collection of blood within the brain parenchyma or ventricular system
that is not caused by trauma. 1 It is a heterogeneous condition resulting
from several distinct underlying vasculopathies. Several interacting and
overlapping risk factors may play a role in the vessel rupture.
The overall incidence of ICH ranges from 15 to 40 per 100,000 person-years. 2–4
ICH accounts for 10–15 % of all strokes, but this proportion may be higher in
Asian populations. 5–7 The risk of ICH increases with age, being 9.6-fold higher
in people over 85 years old compared with those less than 45 years of age. 8
ICH incidence is higher in men, especially in Asian populations. 3 Despite
a significant improvement in ischaemic stroke management, ICH treatment
has not significantly changed and this condition remains associated with
a high case fatality rate in the first month, ranging from 13 to 61 % of
patients, with a median of 40 % across studies. 3
The clinical and epidemiological scenario of ICH has been changing
in the last decades. 2,9,10 Despite an overall stable incidence of ICH,
the incidence among people older than 75 years has increased and the
incidence among people younger than 60 years has decreased, with a
larger proportion of lobar haemorrhages, suggesting that vasculopathies
more strongly associated with the elderly, particularly cerebral amyloid
angiopathy (CAA), represent an increasing proportion within the
aetiological distribution of ICH. 10 The poor prognosis of ICH may be partly
due to our poor understanding of this heterogeneous disease. Herein,
we review the different causes of ICH.
© TO U CH MED ICA L MEDIA 201 4
Anatomical Distribution (see Figure 1)
ICH location can be classified as deep, lobar and infratentorial (involving
the cerebellum and/or the brainstem). The anatomical distribution of the
haemorrhage and its extension to other compartments (subarachnoid,
subdural, intraventricular) may bring clues to identify the underlying
cause of the bleeding.
Our knowledge on the anatomical distribution remains imprecise
because most estimates are based on hospital series, which suffer
from bias (referral is less often considered for moribund patients or, at
the other extreme, for patients with only mild deficits), and population-
based studies, which are unbiased might contain a small proportion
of haemorrhages precluding any further anatomical subdivision. 1,9,11 In
population-based registries, deep ICH accounts for 60–65 % while lobar
ICH accounts for 31–40 % of all ICH cases. 9,11 Multiple ICH accounts from
0.7–4.7 % 12,13 of all ICH cases.
The pooled 1-year survival estimate in nine population-based studies
was 46 % (95 % confidence interval [CI] 43 to 49), while when location is
considered the 1-year survival was 45–59 % after lobar ICH, 45 to 59 %
after deep ICH and 40 to 54 % after infratentorial ICH. 14
The most frequent cause of deep ICH is deep perforating vasculopathy
that supervenes mostly in small perforating arterioles (50–700 µm in
diameter) originating from the middle cerebral artery and from the
basilar artery, thus explaining the classic location in the basal ganglia