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Intracerebral Hemorrhage

By

Ji Y. Chong

, MD, Weill Cornell Medical College

Last full review/revision Jul 2020| Content last modified Jul 2020
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An intracerebral hemorrhage is bleeding within the brain.

  • Intracerebral hemorrhage usually results from chronic high blood pressure.

  • The first symptom is often a severe headache.

  • Diagnosis is based mainly on results of imaging tests.

  • Treatment may include managing problems that may contribute to bleeding (such as lowering blood pressure if it is very high) and, rarely, surgically removing the accumulated blood.

Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher percentage of deaths due to stroke. Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage (bleeding around, rather than within, the brain).

Bursts and Breaks: Causes of Hemorrhagic Stroke

When blood vessels of the brain are weak, abnormal, or under unusual pressure, a hemorrhagic stroke can occur. In hemorrhagic strokes, bleeding may occur within the brain, as an intracerebral hemorrhage. Or bleeding may occur between the inner and middle layer of tissue covering the brain (in the subarachnoid space), as a subarachnoid hemorrhage.

Bursts and Breaks: Causes of Hemorrhagic Stroke

Causes

Intracerebral hemorrhage most often results from

  • Chronic high blood pressure (hypertension), which weakens a small artery, causing it to burst

Risk factors that contribute to this type of hemorrhage include

  • Cigarette smoking

  • Obesity

  • An unhealthy diet (such as one that is high in saturated fats, trans fats, and calories)

Using cocaine or amphetamines can cause temporary but very high blood pressure and hemorrhage. In some older people, an abnormal protein called amyloid accumulates in arteries of the brain. This accumulation (called amyloid angiopathy) weakens the arteries and can cause hemorrhage.

Less common causes include blood vessel abnormalities present at birth, a bulge in arteries of the brain (cerebral aneurysm), an abnormal connection between arteries and veins (arteriovenous malformation) within the skull, injuries, tumors, inflammation of blood vessels (vasculitis), bleeding disorders, and use of anticoagulants in doses that are too high. Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.

Symptoms

An intracerebral hemorrhage begins abruptly. A severe headache is common. In many people, an intracerebral hemorrhage causes a change in consciousness, often within seconds or a few minutes. People may become less aware of their surroundings and less able to understand, remember, and think clearly. Nausea, vomiting, and seizures are common.

If the hemorrhage is small, consciousness may not be affected, and headache or nausea may be mild or absent.

However, symptoms suggesting brain dysfunction develop suddenly and steadily worsen as the hemorrhage expands.

Some symptoms, such as weakness, paralysis, loss of sensation, and numbness, often affect only one side of the body. People may be unable to speak or become confused. Vision may be impaired or lost. One or both eyes may be unable to move in certain directions. As a result, the eyes may point in different directions.

Diagnosis

  • Computed tomography or magnetic resonance imaging

  • A blood test to measure blood sugar

  • Blood tests to determine whether blood is clotting normally

Doctors can usually suspect intracerebral hemorrhage based on symptoms and results of a physical examination.

The blood sugar level is measured immediately because a low blood sugar level can cause symptoms similar to those of stroke.

Blood tests are also done to measure the number of platelets (which help blood clot) and to determine how long it takes blood to clot. The number of platelets (platelet count) may be low for many reasons. A low platelet count can increase the risk of bleeding. Blood clotting may be affected by a dose of warfarin that is too high, liver failure, or other disorders.

Computed tomography (CT) or magnetic resonance imaging (MRI) is done immediately to confirm the diagnosis. Both tests can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The tests can also show how much brain tissue has been damaged and whether pressure is increased in other areas of the brain.

Doctors sometimes do CT angiography (CT done after a contrast agent is injected into a vein) to determine whether the hemorrhage is continuing to expand. If it is expanding, the outlook is poor.

Prognosis

Intracerebral hemorrhage is more likely to be fatal than ischemic stroke. The hemorrhage is often large and catastrophic, especially in people who have chronic high blood pressure. About half the people who have a large hemorrhage die within a few weeks. Those who survive usually recover consciousness and some brain function over time. However, most do not recover all lost brain function.

When the hemorrhage is small, people tend to have a better recovery than those who have an ischemic stroke. Bleeding is less destructive to brain tissue than lack of oxygen, as occurs in ischemic strokes.

Treatment

  • Monitoring and supportive measures as needed

  • Control of risk factors

  • Sometimes treatments to help blood clot

  • Sometimes surgery to remove the accumulated blood

People with an intracerebral hemorrhage are usually admitted to a intensive care unit (ICU). There, they can be monitored, provided with support of vital functions (such as breathing) as needed, and treated for any problems that occur.

Treatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin and warfarin), thrombolytic drugs, and antiplatelet drugs (such as aspirin) are not given because they make bleeding worse.

If people who are taking an anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood clot such as

  • Vitamin K, usually given intravenously

  • Transfusions of platelets

  • Transfusions of blood that has had blood cells and platelets removed (fresh frozen plasma)

  • A solution that contains clotting factors and other proteins that help blood clot (prothrombin complex concentrate)

High blood pressure is treated only if it is very high. Decreasing blood pressure too rapidly or by too much can reduce the blood supply to parts of the brain that have already been deprived of blood because of the hemorrhage. Then, the lack of blood may result in a stroke (an ischemic stroke) in those parts of the brain.

Surgery to remove the accumulated blood and relieve pressure within the skull is rarely done because the operation itself can damage the brain. Also, removing the accumulated blood can trigger more bleeding, further damaging the brain and leading to severe disability. However, this operation may be lifesaving if people have a large hemorrhage in the cerebellum (the part of the brain that helps coordinate the body’s movements).

Antiseizure drugs are given if people have had seizures.

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