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A 58-year-old African American man with a history of hypertension, mechanical mitral valve replacement, alcohol abuse, and atrial fibrillation (AF) suddenly developed nausea, vomiting, and left arm and leg weakness. He takes hydrochlorothiazide (HCTZ) 25 mg every morning for hypertension, metoprolol-XL 25 mg/day, and warfarin 5 mg/day. His wife promptly called 911 and the emergency medical services (EMS) arrived on the scene. The time of onset of symptoms was established to be approximately 20 minutes ago. A quick Cincinnati Pre-hospital Stroke Scale assessment shows left-sided weakness including face, arm, and leg and a Glasgow Coma Scale (GCS) of 12. Oxygen was applied through a nasal cannula and intravenous access was secured. The EMS personnel suspected a stroke and they notified the destination hospital.

On arrival at the emergency department, the patient was found to be more somnolent (GCS is 8) and responsive to painful stimulus. Vital signs are BP: 220/120 mm Hg, HR: 120 to 130 bpm, RR: 24, blood sugar by fingerstick: 182 mg/dL, and cardiac monitor shows a rapid AF. Initial computed tomographic (CT) scan showed a left frontoparietal intracerebral hemorrhage (ICH) (Figure 2-1) and the International Normalized Ratio (INR) was 5.8.

Figure 2-1.

CT scan showing this patient's right basal ganglia ICH with small extravasation into the right lateral ventricle.

What are the risk factors for ICH?

Hypertension (HTN) is the most important and prevalent of the risk factors for ICH, leading to a form of vasculopathy termed lipohyalinosis. Nonmodifiable risk factors include advanced age, male gender, and African American and Japanese race/ethnicity. 1-4 Additionally, cerebral amyloid angiopathy (CAA), although usually asymptomatic, is an important risk factor for primary ICH in the elderly. CAA is characterized by the deposition of β-amyloid protein in small- to medium-sized blood vessels of the brain and leptomeninges, which may undergo fibrinoid necrosis as seen in chronic HTN. Other risk factors include cocaine use, low cholesterol levels, oral anticoagulants, and excessive alcohol abuse. 2, 5-14

How do we reliably establish the diagnosis of ICH?

The diagnosis of ICH is suggested by the rapid onset of neurologic dysfunction and signs of increased intracranial pressure (ICP), such as headache, vomiting, and decreased level of consciousness. The symptoms of ICH are related primarily to the etiology, anatomic location, and extension of the expanding hematoma. Abnormalities in the vital signs such as hypertension, tachycardia, or bradycardia (Cushing response) and abnormal respiratory pattern are common effects of elevated ICP. Confirmation of ICH cannot rely solely on the clinical examination and requires the use of an emergent CT scan (see Figure 2-1) or magnetic imaging (MRI) and will differentiate between ischemic and hemorrhagic strokes. The CT scan rapidly evaluates the size and location of the hematoma, extension into the ventricular system, ...

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