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.
(See also Overview of Stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction). Symptoms occur suddenly... read more and Overview of Hemorrhagic Stroke Overview of Hemorrhagic Stroke Hemorrhagic strokes include bleeding within the brain (intracerebral hemorrhage) and bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid hemorrhage). ... read more .)
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 Subarachnoid Hemorrhage (SAH) A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissues covering the brain (meninges)... read more (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.
Causes of Intracerebral Hemorrhage
Intracerebral hemorrhage most often results from
Risk factors that contribute to this type of hemorrhage include
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 Brain Aneurysms An aneurysm is a bulge (dilation) in the wall of an artery. Aneurysms that occur in the arteries of the brain (cerebral arteries) are called cerebral aneurysms. Aneurysms may occur in any artery... read more ), an abnormal connection between arteries and veins (arteriovenous malformation Brain Arteriovenous Malformations (AVMs) An arteriovenous malformation is a tangle of dilated blood vessels that directly connect arteries and veins, bypassing the capillaries (which normally connect arteries and veins). Brain arteriovenous... read more ) within the skull, injuries, tumors, inflammation of blood vessels (vasculitis Overview of Vasculitis Vasculitic disorders are caused by inflammation of the blood vessels (vasculitis). Vasculitis can be triggered by certain infections or drugs or can occur for unknown reasons. People may have... read more ), 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 of Intracerebral Hemorrhage
An intracerebral hemorrhage begins abruptly, often during activity. A severe headache is common. However, headache may be mild or absent in older people.
Many people lose consciousness when an intracerebral hemorrhage occurs, often within seconds or a few minutes. Or 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, as the hemorrhage expands, symptoms suggesting brain dysfunction develop suddenly and steadily worsen.
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.
Large hemorrhages increase pressure within the skull. Sometimes the increased pressure pushes the brain downward and forces it through the rigid structures that separate the brain into compartments. The result is a serious problem called herniation Herniation: The Brain Under Pressure . Pressure may be put on areas that control consciousness and breathing in the brain stem Brain stem The brain’s functions are both mysterious and remarkable, relying on billions of nerve cells and the internal communication between them. All thoughts, beliefs, memories, behaviors, and moods... read more (which connects the cerebrum with the spinal cord). Herniation can cause loss of consciousness, coma, irregular breathing, and death.
Another serious problem is hydrocephalus. It occurs when cerebrospinal fluid (which surrounds the brain and spinal cord) is blocked from leaving the brain. The fluid accumulates within the brain and puts additional pressure on it. Hydrocephalus may contribute to symptoms caused by the hemorrhage, such as headaches, sleepiness, confusion, nausea, and vomiting and may increase the risk of coma and death.
Large hemorrhages are fatal within a few days in about half of people. In survivors, consciousness returns and problems caused by the hemorrhage usually gradually lessen as the blood is absorbed. Some people have surprisingly few problems because hemorrhage is less destructive to brain tissue than an inadequate blood supply.
Diagnosis of Intracerebral Hemorrhage
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. A low number of platelets (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 angiography Computed tomography (CT) is a type of medical imaging that combines a series of x-rays to create cross-sectional, detailed images of internal structures. In computed tomography (CT), which used... read more (CT done after a contrast agent is injected into a vein) to determine whether the hemorrhage is due to a specific abnormality in a blood vessel, such as an aneurysm or arteriovenous malformation.
Treatment of Intracerebral Hemorrhage
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 medications, and antiplatelet medications (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 Treatment High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more 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).
If hydrocephalus Treatment Normal-pressure hydrocephalus consists of difficulty walking, urinary incontinence, and dementia due to an increase in the fluid that normally surrounds the brain. Usually, the main symptoms... read more is present, a surgeon may place a drain (called an external ventricular drain) in the brain to rapidly decrease pressure within the skull. This procedure can be lifesaving. A thin tube is placed in the brain, and the fluid drains into a collection bag outside the body.
Antiseizure medications are given if people have had seizures.
Prognosis for Intracerebral Hemorrhage
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.
The presence of hydrocephalus increases the risk of having a poor outcome.