Spontaneous intracerebral hemorrhage in critically ill patients: Incidence over six years and associated factors

Objective: Intracerebral hemorrhage (ICH) is associated with a high mortality. The present study sought to determine the incidence of spontaneous ICH in an intensive care unit (ICU) and associated factors. Design: A 6 year retrospective study. Setting: A general ICU in a university hospital. Patients: All ICU patients developing ICH were included in the study. All trauma and neurosurgical patients were excluded, as well as patients who were admitted to the ICU because of ICH. Measurements and results: During the study period 3032 patients were hospitalized in the ICU, and 834 were excluded. The remaining 2198 patients comprised the study population. Computed tomography of the head was performed in a total of 227 patients, and the 9 patients found to have new onset ICH comprise the group of interest. None of these patients were hypertensive. Seven of the patients had either a primary hematologic malignancy or bone marrow transplantation. Eight had thrombocytopenia of < 100 x 10⁹/l (median 10 x 10⁹/l, range 3-150 x 10⁹/l), and in 6 it preceded ICH by 5 days or more. Only in one patient were both PTT and PT prolonged. All were mechanically ventilated with high peak inspiratory pressure (PIP) (median 37 cmH₂O, range 20-43 cmH₂O). Arterial carbon dioxide tension (PaCO₂) was considerably elevated (median 65 mmHg, range 41-87 mmHg. All of the patients had impaired renal and hepatic function (urea: median 14 mmol/l, range 9.9-52 mmol/l; bilirubin: median 94 μ mol/l, range 20-360 μ mol/l), and five had septicemia. Eight of the patients bled to other sites before they developed ICH. All patients died shortly after the diagnosis of ICH. Conclusions: Spontaneous nonhypertensive ICH is a rare, fatal event in the ICU. Associated factors include thrombocytopenia, the need for mechanical ventilation, elevated PIP and PaCO₂, sepsis, and impaired hepatic and renal function.