Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cerebral Hemorrhage


Related Terms

  • Brain Hemorrhage
  • Cerebellar Hemorrhage
  • Cerebellum Hemorrhage
  • Cerebral Parenchymal Hemorrhage
  • Cerebrovascular Accident (CVA)
  • Cerebrum Hemorrhage
  • Cortical Hemorrhage
  • Hemorrhagic Cerebrovascular Accident
  • Hemorrhagic Stroke
  • Intracerebral Bleed
  • Intracerebral Hemorrhage
  • Intracerebral Hemorrhage (ICH)
  • Intracranial Hemorrhage
  • Stroke
  • Subcortical Hemorrhage

Differential Diagnosis

Specialists

  • Neurologist
  • Neuroradiologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Speech Therapist

Comorbid Conditions

  • Aneurysm
  • Arteriovenous malformation
  • Bleeding disorders
  • Cerebral amyloid angiopathy
  • Diabetes
  • Hypercholesterolemia
  • Hypertension
  • Obesity

Factors Influencing Duration

The location, size, and etiology of the ICH, coupled with the length of time between the onset of symptoms and start of treatment, affect the extent and duration of disability. Individuals may have ongoing difficulties with speech and comprehension or experience neurologic deficits and permanent physical limitations.

For individuals requiring craniotomy or craniectomy, duration depends on the site of the hemorrhage, size, severity, and underlying cause. Duration reflects recovery from procedure only. Residual impairments in survivors may be severe, precluding employment.

Medical Codes

ICD-9-CM:
431 - Intracerebral Hemorrhage
432.9 - Intracranial Hemorrhage, Unspecified; Intracranial Hemorrhage NOS
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

Overview

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 also includes subdural hemorrhage and epidural hemorrhage. Intracranial hemorrhage has a number of causes, and the reader is referred to the topics Cerebrovascular Disease, Intracranial Hemorrhage, and Cerebrovascular Accident for additional information.

A stroke is sudden, localized damage in the brain due to impaired blood supply 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 (ICH or hemorrhagic stroke).

The skull is a closed compartment which is very sensitive to even small increases in volume. Thus, bleeding into or around the brain or even slight swelling of the brain can produce dramatic changes ranging from neurological deficits to death.

Incidence and Prevalence: Incidence of ICH in the US is 12 to 15 per 100,000 individuals (Liebeskind). Of all strokes in the US, 10% are intracerebral hemorrhagic strokes (Go). The incidence of all strokes combined is approximately 800,000 annually in the US (Go).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Specific risk factors for ICH and hemorrhagic stroke include high blood pressure (hypertension), diabetes, atrial fibrillation and other disorders of heart rhythm, pregnancy and the post-pregnancy period, use of anticoagulant agents, history of transient ischemic attack (TIA), drug abuse, 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. Stroke and ICH occur more often among populations with a higher prevalence of hypertension, including blacks. The incidence of all intracranial hemorrhages increases with age. About half of all childhood strokes are hemorrhagic (Go).

The most common causes of cerebral hemorrhage are damage to blood vessel walls hypertension, hypertension during the later stages of pregnancy (eclampsia), and drug abuse (especially cocaine use). Other causes of ICH 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, or vasculitis.

Source: Medical Disability Advisor



Diagnosis

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 ICH 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). Convulsive and nonconvulsive seizures occur in 7% to 17% of strokes and about 20% of intracranial hemorrhages, respectively (Gilmore).

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 (prothrombin time [PT] and partial thromboplastin time [PTT]), electrolytes, blood glucose, blood typing and crossmatching, 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 computed tomography (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 magnetic resonance imaging (MRI) to reveal ICH 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 ICH.

Because of risk of brain herniation, spinal tap (lumbar puncture) is generally avoided if ICH is suspected or has been documented on CT or MRI. Electrocardiograms (ECGs) and chest x-rays can identify irregular heartbeats caused by the ICH and any associated cardiac injury or comorbidity.

Source: Medical Disability Advisor



Treatment

Immediate transport to the nearest emergency department is critical. Cardiac and blood pressure monitoring is critical. 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.

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.

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



Prognosis

Factors that carry a poor prognosis following ICH include reduced level of consciousness when the individual is first seen, extension of the hemorrhage into the ventricular system which circulates cerebrospinal fluid (CSF) (intraventricular hemorrhage), increased size of hemorrhage, accumulation of CSF within the skull (hydrocephalus), advanced age, and gender. Males over age 75 statistically have the worst outcome (Zia; Thanh).

Stroke is the fourth leading cause of death in the US and the tenth leading cause of disability (CDC). About 25% of individuals die within the first 28 days. Men are more likely to die than women, especially those over the age of 75. Bleeding in the brainstem and to a lesser extent central brain is associated with higher mortality.

Although there is often residual impairment, some individuals who survive ICH 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



Rehabilitation

The type and duration of rehabilitation depends on the site of the ICH 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



Complications

Complications of ICH 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 (DVT), pulmonary emboli, and urinary tract infections or complications.

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 and/or death.

Depending on the location of the ICH, residual deficits may include weakness or paralysis on one side (hemiparesis or hemiplegia), aphasia, problems with memory, and other neurological impairments. Depression is a significant factor in the quality of life for hemorrhagic stroke survivors (Christensen).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

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.

Risk: Generally, there are no occupations that place peripheral circulatory disorders at risk unless there are certain metal exposures (Melhorn, 459-460).

Capacity: Capacity may be affected in individuals who sustained permanent damage following ICH. Depending on the area of the brain affected, testing for disability is needed.

Tolerance: Tolerance may be affected in individuals who experience a permanent deficit from their stroke. Rehabilitation is often an important mechanism to encourage use of an affected body part and re-integration into the work environment. Worksite accommodations and Americans with Disabilities Act (ADA) considerations may become pertinent in the discussion.

Source: Medical Disability Advisor



Maximum Medical Improvement

360 days (varies based on size and location).

Source: Medical Disability Advisor



Failure to Recover

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?
  • Does individual have a history of a bleeding disorder such as hemophilia?
  • Does individual have a history of small strokes (TIAs)?
  • Does individual take prescribed blood thinners (anticoagulants or antiplatelet agents)?
  • Was there recent trauma to the head?
  • Does individual smoke?
  • Does individual consume alcohol in excess?
  • Does individual use cocaine?
  • Did individual complain of headache and vomiting at the onset?
  • Were visual disturbances, aphasia, arm or leg weakness (paresis), or impaired consciousness ranging from drowsiness to coma present?
  • Was brain CT done to detect hemorrhages or other intracranial pathology? MRI?
  • Was arteriography of the carotid artery performed, if indicated?
  • Was diagnosis of ICH confirmed?
  • Was cause of the hemorrhage identified?

Regarding treatment:

  • Is individual complying with medical regimen to lower blood pressure, treat cardiac arrhythmias, treat seizures, and relieve arterial narrowing (vasospasm)?
  • Is individual responding to the medications?
  • Were diuretics administered and fluids restricted to reduce brain swelling?
  • Was surgical removal (evacuation) of blood clots performed?
  • If ICH resulted from a ruptured aneurysm, was surgery performed to clip the aneurysm?
  • Is transcranial Doppler or intraventricular pressure monitoring required to optimize treatment?

Regarding prognosis:

  • What was individual’s level of consciousness when first seen?
  • How large was the hemorrhage?
  • What is the age and gender of individual?
  • Was this hemorrhage associated with hypertension?
  • Did hemorrhage extend into the ventricular system that circulates CSF?
  • Did individual sustain brain damage? How did this manifest itself?
  • How much recovery can be expected with rehabilitation?
  • Did individual experience complications such as aspiration pneumonia, acute myocardial infarction, brain artery narrowing (vasospasm), seizures, or herniation of the brain into the spinal canal?
  • What type of neurological damage occurred? Would rehabilitation enable individual to return to some measure of pre-morbid functioning?
  • Is individual in a coma? What are the possibilities that individual will emerge from the coma?

Source: Medical Disability Advisor



References

Cited

"47.5 Million U.S. Adults Report a Disability; Arthritis Remains Most Common Cause." CDC. 21 Jun. 2011. Centers for Disease Control and Prevention. 8 May 2014 <http://www.cdc.gov/features/dsadultdisabilitycauses/>.

"Leading Causes of Death." CDC. 30 Dec. 2013. Centers for Disease Control and Prevention. 8 May 2014 <http://www.cdc.gov/nchs/fastats/lcod.htm>.

Christensen, M. C. , S. Mayer, and J. M. Ferran. "Quality of Life after Intracerebral Hemorrhage: Results of the Factor Seven for Acute Hemorrhagic Stroke (Fast) Trial." Stroke 40 (2009): 1677-1682.

Gilmore, E. , et al. "Seizures and CNS Hemorrhage: Spontaneous Intracerebral and Aneurysmal Subarachnoid Hemorrhage." The Neurologist 16 (2010): 165-175.

Go, A. S. , et al. "Heart Disease and Stroke Statistics--2013 Update: A Report from the American Heart Association." Circulation 127 (2013): e6-e245.

Jauch, Edward C., et al. "Acute Management of Stroke." eMedicine. Eds. Helmi L. Lutsep, et al. 2 Oct. 2012. Medscape. 8 May 2014 <http://emedicine.medscape.com/article/1159752-overview>.

Liebeskind, David S. "Hemorrhagic Stroke." eMedicine. Eds. Rick Kulkarni, et al. 8 Mar. 2013. Medscape. 8 May 2014 <http://emedicine.medscape.com/article/1916662-overview>.

Liebeskind, David S. "Intracranial Hemorrhage." eMedicine. Eds. Helmi L. Lutsep, et al. 23 Jan. 2013. Medscape. 8 May 2014 <http://emedicine.medscape.com/article/1163977-overview>.

Melhorn, J. M. , et al. (2nd Ed.) Disease and Injury Causation, Guides to the Evaluation of. 2nd ed. New York: American Medical Association, 2013.

Phan, T. G. , et al. "Hydrocephalus Is a Determinant of Early Mortality in Putaminal Hemorrhage." Stroke 31 (2000): 2157-2162.

Zia, E. , et al. "Three-Year Survival and Stroke Recurrence Rates in Patients with Primary Intracerebral Hemorrhage." Stroke 40 (2009): 3567-3573.

General

"Stroke." MedlinePlus. 28 May. 2013. National Library of Medicine. 8 May 2014 <http://www.nlm.nih.gov/medlineplus/ency/article/000726.htm>.

Source: Medical Disability Advisor






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