Stranger causes of ICH

As a neurologist, most of the intracerebral hemorrhages (ICH) I encounter are due to hypertension. But the most common cause of ICH worldwide is trauma. These patients usually go to the OR.

The purpose of this week’s episode is to review many of the non-hypertensive causes of spontaneous ICH in adults:

Definitely recommend checking out the episode, but for those who want the quick and dirty version, check out our Cliff notes here…

Unusual history worth screening for

  • On active anticoagulation

    A 52-year-old gentleman presented with acute headache, nausea, and gait difficulty. Head CT revealed a concentric hyperdense lesion with mass effect. Prior MRI from 3 years earlier had identified a 15 mm cerebellar cavernoma, which was thought to have acutely hemorrhaged in this symptomatic patient.

  • History of coagulopathy
  • History of cancer
  • Substance abuse

Things you never want to miss

  • Cerebral vein thrombosis
  • Metastatic lesion(s)
  • Vascular malformation
  • In all seriousness, you never really want to miss any cause of ICH…

Things that affect young patients

  • Sympathomimetic drugs
  • Vascular malformations (AVMs, dural AVFs, cavernomas)
  • Reversible cerebral vasoconstriction syndrome (SSRIs, other medications)

Things that affect older patients

  • Cerebral amyloid angiopathy

    A 78-year-old gentleman with a left frontotemporal intracranial hemorrhage. Excision of the mass confirmed the diagnosis of gliobastoma multiforme.

  • Metastatic lesion(s)

Infectious causes

Things that affect multiple intracranial compartments

  • Trauma!!
  • Coagulopathy
  • AComm or M2 aneurysm(s)
  • Dural arteriovenous fistulas
  • Sympathomimetic use
  • Reversible cerebral vasoconstriction syndrome
  • Venous sinus thrombosis

And that about sums it up for atypical causes of ICH. But for those of you who want to hear Dr. Steven Messe’s voice, I would refer you to the episode. He has also been on the Neurology podcast from December 2016, so check that episode out to brush up on the national trends in treating acute stroke.


[Jim Siegler]

The content in this episode was vetted and approved by Steven Messe.


Ducruet AF, et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurgical Review 2010;33: 37.

Morgenstern LB, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke .

Qureshi AI, et al. Spontaneous intracerebral hemorrhage. New Eng J Med 2001; 344:1450-1460.

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