What is Intracerebral Hemorrhage?
When blood vessels within the brain become damaged, they are more likely to burst and cause a hemorrhage. An intracerebral brain hemorrhage (ICH) is bleeding in the brain caused by the rupture of a damaged blood vessel in the head. Bleeding in the brain rapidly increases the pressure in the brain which can lead to the damage of brain cells, unconsciousness or even death. Alternative names for intracerebral hemorrhage include intracranial hemorrhage, hypertensive hemorrhage and hemorrhagic stroke.
Causes and Risks
Intracerebral hemorrhage affects people of all ages. The most common cause of ICH is chronic high blood pressure. Because there are no warning signs (symptoms), risk of ICH is undetected until a major event occurs, known as a hypertensive intracerebral hemorrhage. Other common causes or factors that raise the risk of ICH include the following:
- Abnormalities in the blood vessels (aneurysms or vascular malformations)
- Amyloid angiopathy, a neurological condition in which proteins called amyloid build up on the walls of arteries in the brain
- Brain tumors
- Blood and bleeding disorders:
- Decreased levels of blood platelets
- Disseminated intravascular coagulation
- Clotting disorders, such as hemophilia or Von Willebrand’s disease (hereditary bleeding disorder)
- Sickle cell anemia
- Liver disease, which is associated with an increased bleeding risk
- Use of aspirin or blood thinners (anticoagulant medications)
People are at greater risk for ICH if they:
- Have high blood pressure
- Have had a recent stroke
- Are African-American or Hispanic
Premature infants (born earlier than 35 weeks) can sometimes have bleeding into the fluid-filled spaces (ventricles) in the brain. This type of bleed is called intra-ventricular hemorrhage (IVH). This can occur in the first few days after the child is born and is usually not preventable.
Symptoms will vary depending on the location of the bleed and the amount of brain tissue affected. However, they usually develop suddenly, without warning, and oftentimes during an activity. Please also see section pertaining to your underlying cause of ICH (ex. If you had an ICH due to AVM, please see that section). This will give you a more accurate list of symptoms specific to your condition. Symptoms can include:
- Abnormal sense of taste
- Change in alertness (level of consciousness)
- Apathetic, withdrawn
- Sleepy, lethargic, stuporous
- Unconscious, comatose
- Difficulty speaking or understanding speech
- Difficulty swallowing
- Difficulty writing or reading
- May occur when lying flat
- May awaken patient from sleep
- May increase with change in position
- May increase with bending, straining, and coughing
- Loss of coordination
- Loss of Balance
- Movement changes
- Difficulty moving any body part
- Hand tremor
- Loss of fine motor skills
- Weakness of any body part
- Nausea, vomiting
- Sensation changes
- Abnormal sensations
- Decreased sensation
- Facial paralysis
- Numbness or tingling
- Vision changes
- Any change in vision
- Decreased vision, loss of all or part of vision
- Double vision
- Eyelid drooping
- Pupils different size
- Uncontrollable eye movements
If you experience these symptoms, call 911 immediately.
Diagnosis usually begins with a neurological exam and includes computed tomography (CT) and magnetic resonance imaging (MRI) scans of the brain. Additional tests may include a diagnostic cerebral angiogram, an electroencephalogram (EEG), and cerebral blood flow tests. Blood tests can detect defects in the blood clotting system and signs of inflammation or immune system disorders. Time is of the essence to prevent and treat ICH.
Treatment of an ICH depends on the location, cause, and amount of hemorrhage. Following hemorrhage, patients are closely monitored in our neurointensive care unit where the physician comes up with a treatment plan specific to that patient’s cause of bleeding, and medical history. Control of blood pressure and support of the lungs and respiratory system are important features of intensive care for these patients.
Pressure in the brain can be monitored using a ventricuostomy. If the pressure is elevated this device can be used to drain cerebrospinal fluid from the ventricle. This device can also be used to drain blood that has collected in the brain as a result of the hemorrhage. A ventriculostomy can be placed by a neurosurgeon either at the bedside, or in an operating room. For additional information on neuromonitoring devices, please see Neurocritical Care document.
A decompressive craniotomy may be required to relieve intracranial (within the skull) pressure caused by bleeding. This procedure is only considered for severe brain injuries or swelling that cannot be controlled by means of medication or ventriculostomy. Considerations include the location and size of the hemorrhage, the patient’s age and medical condition, and the likelihood of the patient recovering from the hemorrhage. If it is not an emergent situation, it may be delayed 1-2 weeks in order to allow the patient’s condition to stabilize. This treatment is only performed by a neurosurgeon in an operating room. The surgeon first makes an incision in the scalp, then through the bone using a special saw, which allows a piece of the skull to be removed. This gives the brain space to swell without causing further damage. While this procedure improves the chances of survival for most patients, severe swelling may still result in long term deficits, or even death.
Surgery may be required to remove a large hematoma (blood clot), however smaller hematomas may not require surgery. If the blood is localized and isn’t clotting, the doctor may create a burr hole in the skull and use suction to remove the fluid. Larger hematomas will require a craniotomy to remove the blood. Surgery is also required if there is bleeding in the cerebellum. If an abnormal blood vessel or AVM is found, surgery may be required to correct and prevent future brain hemorrhage. If a tumor is found, surgery may be required to remove it. The physician may prescribe painkillers, anticonvulsants to control seizures, and corticosteroids or diuretics to reduce swelling. The patient may need blood, blood products, or IV fluids to make up for loss of blood and fluids. If the cause of ICH was hypertension, the physician will treat the patient with blood pressure medication. Other treatments may be recommended, depending on the patient’s condition and symptoms. For more information on treatment options, please see section pertaining to your underlying cause of ICH (ex. If you had an ICH due to AVM, please see that section). This will give you a more accurate explanation of treatments specific to your condition.
Please see specific section pertaining to your underlying cause of ICH to get a more accurate explanation of outcome.
The patient may experience a complete recovery, but there will usually be some permanent loss of brain function. Death is possible and may occur quickly despite prompt medical treatment. Recovery depends on the amount of blood that bleeds into the brain, the area where the bleeding occurs, the patient’s age, and the initial neurological state of consciousness. The patient may also experience side effects of medications used to treat the disorder.