Hemorrhage - intracerebral

Definition

An intracerebral hemorrhage is bleeding in the brain caused by the rupture of a blood vessel within the head. See also hemorrhagic stroke.

Alternative Names

Causes

Internal bleeding can occur in any part of the brain. Blood may accumulate in the brain tissues itself, or in the space between the brain and the membranes covering it. The bleeding may be isolated to part of one hemisphere (lobar intracerebral hemorrhage) or it may occur in other brain structures, such as the thalamus, basal ganglia, pons, or cerebellum (deep intracerebral hemorrhage).

An intracerebral hemorrhage can be caused by a traumatic brain injury or abnormalities of the blood vessels (aneurysm or angioma). When it is not caused by one of these conditions, it is most commonly associated with high blood pressure (hypertensive intracerebral hemorrhage). In some cases, no cause can be found.

Blood irritates the brain tissues, causing swelling (cerebral edema). It can collect into a mass called a hematoma. Either swelling or a hematoma will increase pressure on brain tissues and can rapidly destroy them.

Symptoms vary depending on the location of the bleed and the amount of brain tissue affected. The symptoms usually develop suddenly, without warning, often during activity. They may occasionally develop in a stepwise, episodic manner or they may get progressively worse.

Other factors that raise the risk of intracerebral hemorrhage include the following:

• Blood and bleeding disorders
  • Disseminated intravascular coagulation
  • Hemophilia
  • Sickle cell anemia
  • Leukemia
  • Decreased levels of blood platelets
• Use of aspirin or anticoagulant medications (blood thinners)
• Liver disease (associated with increased bleeding risk in general)
• Cerebral amyloid or brain tumors

Premature infants (born earlier than 35 weeks gestation) will sometimes have bleeding into the ventricles (fluid-filled spaces) in the brain. This type of bleed is called intra-ventricular hemorrhage (IVH). This occurs in the first day or so of life and is usually not preventable. The outcome is variable, depending on the severity of bleed and ranges from no apparent damage to severe disability. Diagnosis is by ultrasound and usually done in an intensive care nursery.

Symptoms

• Headache
  • May occur when lying flat
  • May awaken patient from sleep
  • May increase with change in position
  • May increase with bending, straining, and coughing
• Nausea, vomiting
• Change in alertness (level of consciousness)
  • Apathetic, withdrawn
  • Sleepy, lethargic, somnolent, stuporous
  • Unconscious, comatose
• Vision changes
  • Any change in vision
  • Decreased vision, loss of all or part of vision
  • Pupils different size
  • Uncontrollable eye movements
  • Eyelid drooping
• Sensation changes
  • Decreased sensation
  • Numbness or tingling
  • Abnormal sensations
  • Facial paralysis
• Difficulty speaking or understanding speech
• Difficulty swallowing
• Difficulty writing or reading
• Movement changes
  • Weakness of any body part
  • Difficulty moving any body part
  • Loss of fine motor skills
  • Hand tremor
• Loss of coordination
• Loss of balance
• Seizure
• Abnormal sense of taste

Exams and Tests

A neurological exam may suggest increased intracranial pressure or decreased brain functions. The person's specific symptoms can help tell which part of the brain is affected.

An eye exam may show swelling of the optic nerve from increased pressure in the brain. There may be changes in eye movement, abnormal reflexes, decreased vision, loss of movement or coordination, or inability to feel sensations properly.

Tests may include:

• CBC
• Platelet count
• Bleeding time
• Prothrombin time (PT) or partial thromboplastin time (PTT)
• Liver function tests
• Kidney function tests
• Head CT scan
• Head MRI or MRA
• Cerebral angiography or spiral CT scan angiography of the head to look for an aneurysm or arteriovenous malformation

Treatment

An intracerebral hemorrhage is a severe condition requiring prompt medical attention. It may develop quickly into a life-threatening situation.

Treatment depends on the location, cause, and extent of the hemorrhage.

Surgery may be needed, especially if there is bleeding in the cerebellum. Surgery may also be done to repair or remove structures causing the bleed (such as a cerebral aneurysm or arteriovenous malformation

Medicines used may include painkillers, corticosteroids or diuretics to reduce swelling, and anticonvulsants to control seizures. Blood, blood products, and intravenous fluids may be needed to make up for loss of blood and fluids. Other treatments may be recommended, depending on the condition of the person and the symptoms that develop.

Outlook (Prognosis)

How well a patient does depends on the size of the hematoma and the amount of swelling.

Recovery may occur completely, or there may be some permanent loss of brain function. Death is possible, and may quickly occur despite prompt medical treatment.

Medications, surgery, or other treatments may have severe side effects.

Possible Complications

• Hemorrhagic stroke
• Permanent loss of any brain function
• Side effects of medications used to treat the disorder

When to Contact a Medical Professional

Go to the emergency room or call 911 if symptoms indicate intracerebral hemorrhage. This is a life-threatening condition.

Emergency symptoms include:

• Difficulty breathing
• Seizures
• Loss of consciousness
• Inability to speak or swallow
• Paralysis of an arm, leg, or half of the body

Prevention

Treatment and control of underlying disorders may reduce the risk of developing intracerebral hemorrhage. High blood pressure should be treated. Do not stop taking medications unless told to do so by your doctor.

Conditions such as an aneurysm can often be treated before they cause bleeding in the brain.