CURRENT CRITICAL MANAGEMENT OF

SPONTANEOUS INTRACEREBRAL
HAEMORRHAGE (SICH)
Setyo Widi Nugroho
Department of Neurosurgery
Padjadjaran University/Hasan Sadikin Hospital
Bandung

Introduction
Spontaneous intracerebral hemorrhage (SICH)
is a blood clot that arises in the brain
parenchyma in the absence of trauma or
surgery
This entity accounts for 10 to 15% of all strokes
Higher mortality rate than either ischemic stroke
or subarachnoid hemorrhage
Abbrupt elevation of blood pressure rupture of
small penetrating arteries

Pathology & Location

Etiology
Common causes :
hypertension
amyloid angiopathy
coagulopathy
vascular anomalies
tumors, and
various drugs

Diagnostic Procedure
Physical diagnostic
Abrupt onset of consciousness and neurologic deficits

Radiodiagnostic :
CT scanning :
Initial diagnostic modality of choice in SICH

Angiography
should be considered in all cases except those involving
older patients with preexisting hypertension in thalamic,
putaminal, or cerebellar hemorrhage

MRI, MRA

CRITICAL MANAGEMENT
Initial Management :
Identify site of haemorrhage within neuraxis
Clinical exam
Radiodiagnostic : CT Scan ,MRI, MRA, DSA

Prevent subsequent damage from rebleeding

edema, or hypoxia.

Initial steps
Airway & Breathing control
GCS < 8 Intubation
PCO2 : 28 35 mmHg

Circulatory
Blood Pressure
Most patient are hypertensive immediately after a
haemorrhage.

Fluid Management :
Intavenous solution ( euvolume, slight hyperosmolar)
Manitol 20 %

 NGT
Laboratory :
Coagulation study
Blood Gas Analysis
Electrolyte
Blood glucose
Other risk factors

 Medical management :
Antihypertensive agent
gastric cytoprotection
Anticonvulsant
Antibiotics
rehabilitation.

Enteral feeding as soon as possible.

Surgical management
Good theoretical rationale for early
surgical intervention :
patients with moderate to large lobar or basal
ganglia hemorrhages
progressive neurological deterioration
cerebellar hemorrhages larger than 3 cm
brainstem compression and hydrocephalus

 Non Surgical :
Small hemorrhages do not typically benefit
from surgery.
Elderly patients with Glasgow Coma Scale
score less than 5

Between July 2003 -- June 2004, there are 78 cases of

spontaneous intracranial hemorrhage (SICH)

Data is obtained from Dept of Neurosurgery RSHS & Stroke Unit RS.St.Boromeus

Conclusion
Hypertensive is the most etiology factor
SICH
Putaminal hemorrhage is the most located
SICH
Most important initial management is to
Prevent subsequent damage from
rebleeding edema, or hypoxia.
Early surgical management produce better
outcome but need further investigation.