Intracerebral Hemorrhageby Elias A. Giraldo, MD, MS

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Stroke (CVA)  Overview of Stroke Ischemic Stroke Transient Ischemic Attacks Overview of Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage

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—

see Subarachnoid Hemorrhage).

CausesIntracerebral hemorrhage most often results when chronic high blood pressure weakens a small artery, causing it to burst. 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, 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.

SymptomsAn intracerebral hemorrhage begins abruptly. In about half of the people, it begins with a severe headache,

often during activity. However, in older people, the headache may be mild or absent.

Symptoms suggesting brain dysfunction develop 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. The pupils may become abnormally large or small. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes.

DiagnosisDoctors can usually suspect intracerebral hemorrhage based on symptoms and results of a physical examination. Computed tomography (CT) or magnetic resonance imaging (MRI) is done 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 (see CT Angiography) to determine whether the hemorrhage is continuing to expand. If it is expanding, the outlook is poor.

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

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 days. Those who survive usually recover consciousness and some brain function over time. However, most do not recover all lost brain function.

TreatmentTreatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin andwarfarin), 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) Intravenous administration of a synthetic product

similar to the proteins in blood that help blood clot (clotting factors)

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, even if it may be lifesaving, 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 effective for hemorrhage in the cerebellum. In such cases, a good recovery is possible.

Anticonvulsants are given if people have had seizures.