Hemorrhage - intracerebral (lobar)

Definition

Lobar intracerebral hemorrhage is bleeding in the largest part of the brain called the cerebrum.

Alternative Names

Causes

Lobar intracerebral hemorrhage (ICH) may be caused by traumatic brain injury or blood vessel problems, such as aneurysm, arteriovenous malformation, or angioma, a type of blood vessel tumor.

When it is not caused by trauma, lobar intracerebral hemorrhage is considered a type of hemorrhagic stroke, the most serious type of stroke.

Lobar ICH is associated with the apolipoprotein (apo) E gene, which is linked to an increased risk for Alzheimer's disease.

Lobar hemorrhages are also associated with the following:

• Various blood or bleeding disorders, such as disseminated intravascular coagulation, hemophilia, sickle cell anemia, and leukemia.
• Decreased levels of blood platelets
• Use of aspirin or blood thinners
• Liver disease (associated with increased bleeding risk)
• Cerebral amyloid
• Some autoimmune disorders

Symptoms

Symptoms usually develop suddenly, without warning, often during activity. The symptoms vary, depending on the location of the bleeding and the amount of brain tissue affected.

A change in alertness or level of consciousness is the first symptom in about 50% of people, including children. The person may seem:

• Apathetic, withdrawn
• Sleepy, lethargic, stuporous
• Unconscious, comatose
• Dementia before the bleed occurs (rare in children) from cerebral amyloid

Other symptoms may include:

• Vomiting
  • Occurs frequently
  • Often described as occurring without nausea
  • Occurs more frequently in the morning
• Headache
  • May develop suddenly
  • May awaken the patient from sleep
  • Increased with change in position
  • Increased with bending, straining, coughing
• Loss of all or part of vision
• Sensation changes
  • Decreased sensation
  • Numbness or tingling
  • Abnormal sensations
• 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/clumsiness
• Loss of coordination
• Loss of balance
• Seizure
• Stiff neck
• Aching of neck, shoulders
• Pain when bending neck
• Loss of muscle function or feeling
• Dysfunctional movement
• Facial paralysis
• Eyelid drooping

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. Some patients with mild hemorrhages may only have a headache.

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 -- may be preferred if bleed is less than 48 hours old
• MRI of head
• Angiography of the head -- may be necessary to determine if there is an aneurysm or arteriovenous malformation

Treatment

The treatment depends on the specific location, extent, and cause of the bleeding. Treatment may include lifesaving measures such as medical hyperventilation, which involves inserting a breathing tube and forcing the the person to breathe rapidly to reduce pressure in the brain.

Surgery may be needed in some cases. Surgery may 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. If a bleeding disorder is present, medications or blood products may be needed to control it.

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

Blood irritates the tissues of the brain and may cause swelling (cerebral edema). Blood collects into a mass (hematoma). Both cerebral edema and the presence of a hematoma within the brain will put increasing pressure on the tissues of the brain and can destroy those tissues.

Blood may collect in the subarachnoid space and irritate the membranes covering the brain (meningeal irritation). Complications will vary depending on the extent of damage and the location of the bleed:

• Hydrocephalus (water on the brain)
• Permanent loss of any brain function
• Side effects of medications used to treat the disorder
• Complications of surgery
• Seizure disorder

When to Contact a Medical Professional

Go to the emergency room or call 911 if anyone has symptoms of a brain hemorrhage.

Any type of intracerebral hemorrhage

Prevention

Treatment and controlling any risk-related disorders may reduce the risk of developing a brain hemorrhage.

High blood pressure should be treated as appropriate. Do not stop taking prescription medications unless advised to do so by your health care provider!Abruptly stopping such medications could lead to this disorder.

If you take blood thinners, your medication dosage needs to be monitored by blood tests, as directed by your health care provider, to make sure that the medications aren't making bleeding too likely and increasing your risk of hemorrhage.

Woo D, Kaushal R, Chakraborty R, et. al. Association of apolipoprotein E4 and haplotypes of the apolipoprotein E gene with lobar intracerebral hemorrhage. Stroke. 2005 Sep;36(9):1874-9.