UMEM Educational Pearls

Primary Intracranial hemorrhage is associated with the following risk factors:

  • hypertension, smoking, alcohol, hypocholesterolemia, genetic factors, warfarin, phenylpropylamine, cocaine and methamphetamine. 

Common causes of secondary ICH are as follows:

  • vascular malformations, arteriovenous malformations, cavernous angiomas, small arterial telangiectasia, and primary and secondary brain tumors.

The question of how to address elevated blood pressure in spontaneous intracranial hemorrhage has been debated.  High blood pressure may cause hematoma expansion, but this has not been proven.  Lowering blood pressure may help reduce neurologic deterioration, but this has also not been proven in the literature. 

The AHA recommended guidelines for blood pressure management in spontaneous ICH are as follows:

If SBP>200 or MAP>150, consider aggressive reduction of BP with continuous IV infusion, monitoring BP every 5 minutes

If SBP>180 or MAP>130, with evidence or suspicion of elevated ICP, consider monitoring ICP and reducing BP using intermittent or continuous IV medications to keep CPP>60 to 80

If SBP>180 or MAP>130 without evidence or suspicion of elevated ICP, then consider a modest reduction of BP (MAP of 110 or targeted SBP 160/90) using intermittent or continuous IV medications, monitoring BP every 15 minutes


Nyquist P: Management of Acute Intracranial and Intraventricular Hemorrhage.  Crit Care Med 2010;38(3):946-953