Intracerebral hemorrhage (ICH) is a subtype of stroke characterized by bleeding directly into the brain parenchyma. It has high mortality and disability rates.

• Most significant modifiable risk factor.
• Leads to small vessel disease (lipohyalinosis, Charcot-Bouchard microaneurysms).
• Classically associated with deep ICH (basal ganglia, thalamus, pons).

• Age-related amyloid-β deposition in leptomeningeal and cortical vessels.
• Associated with lobar hemorrhages.
• Common in elderly; may cause recurrent bleeds.

• Anticoagulants (warfarin, DOACs): ↑ risk, especially with supratherapeutic INR.
• Antiplatelets: mildly increase risk, particularly in older patients or with CAA.

• Chronic: leads to coagulopathy, liver dysfunction, and hypertension.
• Acute: may provoke hypertensive surges.

• Cocaine, amphetamines: cause acute hypertension and vascular damage.

• Promotes vascular injury and increases blood pressure.

• Low LDL and total cholesterol associated with increased ICH risk, especially lobar.

• Risk increases with age.
• CAA-related ICH more common in elderly.

• Slightly more common in males.

• Higher incidence in Asian, Black, and Hispanic populations.

• APOE ε2/ε4 alleles → linked to CAA-related ICH.
• COL4A1/COL4A2 mutations → familial ICH syndromes.

• Chronic exposure associated with increased ICH burden.
• Disproportionately affects low-SES and urban populations.
• See: Air Pollution as a Risk Factor for Intracerebral Hemorrhage.

• Cerebral vascular malformations (AVMs, cavernomas).
• Hemorrhagic transformation of ischemic stroke.
• Neoplasms (primary or metastatic).
• Coagulopathies (congenital or acquired).
• COVID-19–associated coagulopathy.

Note: Risk stratification may differ by hemorrhage location (deep vs lobar vs infratentorial).