| ICD-9-CM: |
| 431 - | Intracerebral Hemorrhage |
| 432 - | Intracranial Hemorrhage, Other and Unspecified |
| 432.9 - | Intracranial Hemorrhage, Unspecified; Intracranial Hemorrhage NOS |
| 853 - | Intracranial Hemorrhage Following Injury, Other and Unspecified |
| 853.0 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, Other and Unspecified |
| 853.00 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, Unspecified State of Consciousness, Other and Unspecified |
| 853.01 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with No Loss of Consciousness, Other and Unspecified |
| 853.02 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Brief (Less than 1 Hour) Loss of Consciousness, Other and Unspecified |
| 853.03 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Moderate (1-24 Hours) Loss of Consciousness, Other and Unspecified |
| 853.04 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness and Return to Pre-existing Conscious Level, Other and Unspecified |
| 853.05 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Prolonged (More than 24 Hours) Loss of Consciousness without Return to Pre-existing Conscious Level, Other and Unspecified |
| 853.06 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Loss of Consciousness of Unspecified Duration, Other and Unspecified |
| 853.09 - | Intracranial Hemorrhage Following Injury without Mention of Open Intracranial Wound, with Concussion, Unspecified, Other and Unspecified |
| A stroke is sudden, localized damage in the brain that results in nervous system (neurologic) deficits. Stroke may result from either interrupted delivery of blood and oxygen to the brain (ischemic stroke) or abnormal bleeding into the brain (cerebral hemorrhage or hemorrhagic stroke). Intracerebral hemorrhage (ICH) is hemorrhage within the brain, whereas intracranial hemorrhage is a broader term and refers to a hemorrhage within the skull. Intracranial hemorrhage includes an intracerebral hemorrhage, but not vice versa. Intracranial hemorrhage has a number of causes, and the reader is referred to the topics Intracranial Hemorrhage and Cerebrovascular Accident for additional information.
The skull is a closed compartment which is very sensitive to even small increases in volume. Thus, bleeding into the brain or even slight swelling of the brain can produce dramatic changes ranging from neurological deficits to death. The most common cause of cerebral hemorrhage is damage to blood vessel walls from high blood pressure (hypertension), high blood pressure during the later stages of pregnancy (eclampsia), or drug abuse (especially cocaine use). Other causes of cerebral hemorrhage include rupture of an aneurysm or arteriovenous malformation (Hypertension and smoking are thought to cause changes in the walls of small arteries that make them more likely to rupture.), inability of the body to regulate blood flow to the brain (e.g., cold exposure, reperfusion injury), diseases that cause changes in the walls of small arteries (e.g., cerebral amyloid angiopathy), bleeding disorders (e.g., hemophilia), use of blood thinning medications (anticoagulant or antiplatelet therapy), trauma, brain tumors (intracranial neoplasm), blood clots in the brain (cerebral venous thrombosis), sickle cell disease, infection, vasculitis, or trauma.Risk: Specific risk factors for cerebral hemorrhage and hemorrhagic stroke include hypertension, eclampsia, use of anticoagulant agents, history of transient ischemic attack (TIA), smoking, obesity, cocaine use, and excessive consumption of alcohol. Individuals with hypertension are more than twice as likely to have hemorrhagic stroke as are individuals with normal blood pressure. Untreated hypertension is associated with greater risk of hemorrhagic stroke than hypertension that is well controlled with medication. The incidence of all intracranial hemorrhages increases after age 55, doubling each decade until age 80 (Liebeskind). Stroke and cerebral hemorrhage occur more often among populations with a higher prevalence of hypertension, including African-Americans (Liebeskind). Incidence and Prevalence: Cerebral hemorrhages account for 10% to15% of all strokes in the US (Nassisi). Incidence of intracranial hemorrhage in the US is 12 to 15 per 100,000 individuals (Liebeskind). The incidence of all strokes combined is approximately 500,000 annually in the US (Nassisi). |
Source: Medical Disability Advisor
| History: It is important to obtain a thorough medical history including history of any prior strokes or TIAs, hypertension, eclampsia, use of anticoagulants, smoking, use of alcohol, use of illicit drugs, and current medications. Typical symptoms of cerebral hemorrhage are a change in the individual’s level of consciousness (ranging from drowsiness to coma), headache, nausea, and vomiting. Other symptoms may include visual disturbances, difficulty talking (aphasia), difficulty swallowing (dysphagia), arm or leg weakness (paresis), or impaired gait (ataxia). Seizures occur in 6% to 7% of intracranial hemorrhages and 28% of hemorrhagic stroke cases, usually within the first 24 hours (Liebeskind; Nassisi). Physical exam: Hypertension usually is noted. The individual’s level of awareness may range from alert, to drowsy, to unconscious (coma). A thorough neurological examination is essential. The type of neurologic deficits noted depend on which part of the brain is involved. Common findings include difficulty or inability in moving a limb or limbs, which may affect the entire right or left side of the body, changes in sensation, aphasia, and visual changes. Tests: Laboratory tests may include a complete blood count (CBC) to screen for infection or anemia, coagulation studies (PT, PTT), electrolytes, blood glucose, blood type and screen, blood alcohol levels, and toxicology screens for substances of abuse. Imaging studies of the brain are essential and should be done as soon as feasible. Brain CT distinguishes hemorrhagic from ischemic stroke and can identify other intracranial pathologies such as tumor or abscess. Evidence of multiple (multifocal) hemorrhages in the occipital, frontal, or temporal areas of the brain suggests recent trauma. Injection of dye (iodinated contrast medium) into the carotid artery (arteriography) sometimes is done, especially if ruptured aneurysm, arteriovenous malformation, or tumor is suspected as the cause of hemorrhage.
The ability of MRI to reveal cerebral hemorrhage improves with the passage of time and is considered reliable at 1 to 2 hours after onset of symptoms. Imaging agents (paramagnetic contrast medium) may be injected to increase visibility of underlying tumors or arteriovenous malformations. MRI can be especially helpful in determining the underlying origin (etiology) of cerebral hemorrhage.
While sometimes useful in detecting underlying etiology of intracranial hemorrhage, spinal tap (lumbar puncture) is generally avoided if cerebral hemorrhage has been documented on CT or MRI because of risk of brain herniation. Electrocardiograms (ECGs) and chest x-rays can identify irregular heartbeats caused by the cerebral hemorrhage and any associated cardiac injury or comorbidity. |
Source: Medical Disability Advisor
| Immediate transport to the nearest emergency department is critical. Cardiac and blood pressure monitoring are critical. Since there is no specific therapy for hemorrhagic stroke, treatment consists of supportive care and correction of any imbalances. For example, if coagulation studies reveal that the blood is not clotting well due to excessive anticoagulant therapy, this can be corrected with the administration of vitamin K and clotting factors.
Other supportive measures include drugs to reduce blood pressure, treat heart rhythm disturbances (arrhythmias), treat seizures, and reduce fever and headache. Antacids may be prescribed to prevent gastric ulcers associated with acute illness. In some instances, fluid restriction and medications to remove excess fluid (diuretics) may be necessary. Assisted breathing (tracheostomy with intubation and mechanical ventilation) may be needed if the individual is in a coma. More frequent, deeper breaths (hyperventilation) may help reduce pressure within the brain by decreasing levels of carbon dioxide. Transcranial Doppler or intraventricular pressure monitoring may be needed to help optimize treatment. Due to the need for a high level of care and frequent monitoring, the individual will be admitted to the intensive care unit.
Some cases may require surgical intervention. Determination is made after considering the location, size, and etiology of the hemorrhage, the individual’s age, level of consciousness, any comorbid conditions, and time elapsed since onset of symptoms. Surgical approaches include: opening the skull (craniotomy) to allow for removal of clots under direct visual observation; stereotactic aspiration of blood under x-ray (radiographic) guidance supplemented with medications to reduce or break up blood clots (thrombolytic agents); and endoscopic evacuation.
If there is residual impairment of the limbs, recovery and rehabilitation may be enhanced by orthopedic reconstructive surgery and/or adaptive bracing of the affected extremities to assist with return to walking and hand function. |
Source: Medical Disability Advisor
| Stroke is the third leading cause of death in the US and the leading cause of disability (Jauch). In cases of cerebral hemorrhage, death results from extensive bleeding that causes increased pressure on the brain resulting in neurological damage. Factors that carry a poor prognosis following cerebral hemorrhage include reduced level of consciousness when the individual is first seen, extension of the hemorrhage into the ventricular system which circulates cerebrospinal fluid (intraventricular hemorrhage), increased size of hemorrhage, accumulation of cerebrospinal fluid within the skull (hydrocephalus), advanced age and sex. Males over age 70 statistically have the worst outcome. Hypertensive hemorrhages are more than five times as likely to be fatal as those not associated with hypertension. Half of all individuals with cerebral hemorrhages caused by hypertension die within the first 48 hours (Nassisi).
Although there is often residual impairment, some individuals who survive cerebral hemorrhage recover completely. Recovery and rehabilitation depend upon the location and extent of bleeding and the degree of damage to brain tissues sustained as a result of the hemorrhage or treatment procedures. |
Source: Medical Disability Advisor
| The type and duration of rehabilitation depends on the site of the hemorrhage and any residual impairments. Types of therapy that may be necessary include physical therapy to help regain muscle strength, endurance, balance, and the ability to walk; occupational therapy to perform activities of daily living such as bathing and dressing; speech therapy to improve verbal and written communication or to regain the ability to swallow; and vocational counseling if new job skills are required. |
Source: Medical Disability Advisor
| The most serious and dreaded complications of a hemorrhagic stroke are increased intracranial pressure and downward movement of the brain into the spinal canal (cerebral herniation), which can compress vital brain structures and lead to coma or death. Other complications of cerebral hemorrhage may include inhalation of mouth or stomach contents into the lungs (aspiration pneumonia), heart attack (acute myocardial infarction), temporary narrowing of brain arteries (vasospasm) causing secondary brain damage, post-stroke seizures, neuropathic pain, deep vein thrombosis, pulmonary emboli, and urinary tract infections or complications. Depending on the location of the hemorrhage, residual deficits may include weakness or paralysis on one side (hemiparesis or hemiplegia), aphasia, problems with memory, and other neurological impairments. Depression affects at least one-third individuals with stroke (Jauch). |
Source: Medical Disability Advisor
| The type and extent of work accommodations that may be required depend upon the degree of brain damage sustained. Safety issues and accommodations revolve around the individual's residual weakness and cognitive impairments. Using and retraining other areas of the brain through rehabilitative therapy, including physical, occupational, and speech therapy may allow the individual to re-learn certain functions. Adaptive devices and architectural modifications may be necessary to accommodate the individual upon return to work. Medications to control hypertension and/or to prevent seizures or blood clots may be prescribed. Individual or workplace education initiatives should stress the importance of treating hypertension effectively, the warning signs of potential stroke, and the adverse effects of alcohol consumption and illicit drug use. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have a history of hypertension? Controlled or uncontrolled?
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Does individual have history of a bleeding disorder such as hemophilia?
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Does individual have a prior history of small strokes (transient ischemic attacks)?
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Does individual take prescribed blood thinners (anticoagulants or antiplatelet agents)?
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Was there recent trauma to the head?
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Does individual smoke?
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Does individual consume alcohol in excess?
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Does individual use cocaine?
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Did individual complain of headache and vomiting at the onset?
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Were visual disturbances, aphasia, arm or leg weakness (paresis), or impaired consciousness ranging from drowsiness to coma present?
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Was brain CT done to detect hemorrhages or other intracranial pathology? MRI?
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Was arteriography of the carotid artery performed, if indicated?
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Was diagnosis of cerebral hemorrhage confirmed?
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Was cause of the hemorrhage identified?
Regarding treatment:
- Was surgical removal (evacuation) of blood clots performed?
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If hemorrhage resulted from ruptured aneurysm, was surgery performed to clip the aneurysm?
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Is individual complying with medical regimen to lower blood pressure, treat heart rhythm disturbances (arrhythmias), treat seizures, relieve arterial narrowing (vasospasm)?
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Is individual responding to the medications?
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Were medications to remove excess fluid (diuretics) administered and fluids restricted to reduce brain swelling?
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Is transcranial Doppler or intraventricular pressure monitoring required to optimize treatment?
Regarding prognosis:
- What was individual’s level of consciousness when first seen?
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Did hemorrhage extend into the ventricular system that circulates cerebrospinal fluid (CSF)?
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How large was the hemorrhage?
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What is the age and sex of individual?
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Was this hemorrhage associated with hypertension?
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Did individual sustain brain damage? How did this manifest itself?
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How much recovery can be expected with rehabilitation?
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Did individual experience complications such as aspiration pneumonia, heart attack (myocardial infarction), brain artery narrowing (vasospasm), seizures, and downward movement of the brain into the spinal canal (herniation)?
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What type of neurological damage occurred? Would rehabilitation return enable individual to return to some measure of pre-morbid functioning?
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Is individual in a coma? What are the possibilities that individual will emerge from the coma?
|
Source: Medical Disability Advisor
| "Hemorrhagic Stroke." MedlinePlus. 20 Oct. 2008. National Library of Medicine. 18 Dec. 2008 <http://www.nlm.nih.gov/medlineplus/ency/article/000761.htm>.Jauch, Edward C., et al. "Acute Stroke Management." eMedicine. Eds. Thomas A. Kent, et al. 9 Apr. 2007. Medscape. 18 Dec. 2008 <http://emedicine.com/neuro/topic9.htm>. Liebeskind, David S. "Intracranial Hemorrage." eMedicine. Eds. Jeffrey L. Saver, et al. 7 Aug. 2006. Medscape. 18 Dec. 2008 <http://emedicine.com/neuro/topic177.htm>. Nassisi, Denise. "Stroke, Hemorrhagic." eMedicine. Eds. Richard S. Krause, et al. 5 Feb. 2008. Medscape. 18 Dec. 2008 <http://emedicine.com/emerg/topic557.htm>. |
Source: Medical Disability Advisor
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