Intracerebral Hemorrhage Overview

There are two major types of stroke. Ultimately, both are a problem characterized by blood not being able to go where it's supposed to.

In ischemic stroke, blood doesn't flow through a blocked artery, and brain cells die from lack of oxygen. In hemorrhagic stroke, blood pours out of a ruptured artery directly into brain tissue rather than flowing through the blood vessels.

Stroke Patient with family holding hands
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Overview

When an artery ruptures in the brain, the blood pushes brain tissue aside as it fights for space inside the skull. As a result, brain tissue is traumatized and can die. If the brain tissue is displaced too much, permanent damage and death can result.

Causes

One common cause of intracerebral hemorrhage is trauma; however, sometimes the hemorrhage just seems to happen on its own.

The most common cause of spontaneous intracerebral hemorrhage is high blood pressure (hypertension). Chronically high blood pressure can weaken the walls of arteries, particularly deep in the brain where small vessels branch off of larger arteries. When high pressure pushes against those weak blood vessel walls, the artery can burst.

It's also not unusual for an ischemic stroke to transform into an area of bleeding. This process is called a hemorrhagic conversion. The ischemic stroke kills brain tissue, and dead brain tissue is more fragile than living brain. This fragility includes the walls of other blood vessels, which are then more likely to rupture. Since ischemic stroke is usually treated with blood thinners, medications can contribute to this kind of intracerebral hemorrhage.

While high blood pressure is the most common cause of spontaneous intracerebral hemorrhage overall, the most likely reason for bleeding varies by age.

In the elderly, a disorder called cerebral amyloid angiopathy can lead to intracerebral hemorrhage. In this disorder, an abnormal protein called amyloid builds up in the walls of blood vessels. This makes the blood vessels more fragile and easily broken. Unlike hypertensive intracerebral hemorrhage, which often happens deep inside the brain, amyloid angiopathy more commonly causes bleeding at the edge of the brain.

In children, congenital vascular abnormalities are the more common cause of spontaneous intracerebral hemorrhage. Fortunately, these are relatively uncommon.

Other contributors to intracerebral hemorrhage include:

  • Brain tumors
  • Vasculitis
  • Septic embolism
  • Moyamoya disease
  • Cocaine and amphetamines
  • Infections such as herpes simplex encephalitis
  • Blood thinning medication
  • Congenital bleeding disorders

Signs

Someone with intracerebral hemorrhage may have neurological signs like numbness, tingling, or weakness, much like an ischemic stroke. The neurological symptoms will depend on the location of the bleed. In addition, the blood can lead to increased pressure in the skull, which leads to headaches, nausea, vomiting, and decreasing consciousness.

Because brain tissue resists compression by blood, the symptoms of intracerebral hemorrhage tend to worsen over minutes to hours. This is in contrast to subarachnoid hemorrhage, which happens all of a sudden.

Diagnosis

In addition to examining the patient, doctors will want to order an urgent computed tomography (CT) scan of the head. New blood will show up brightly on CT scans.

Treatment

By the time an intracerebral hemorrhage is diagnosed, a certain amount of damage will already have been done. The focus will be on stopping the bleeding from getting any worse. Blood pressure will need to be tightly controlled. If there is a blood thinner in the patient's system, medication may be given to reverse it.

The next step is to prevent any side effects from the hemorrhage, such as increased intracranial pressure. To ensure that the patient is well cared for, most patients with intracranial hemorrhage are transferred to a neurological ICU.

Recovery

At one year, mortality in people with intracerebral hemorrhage ranges from 51% to 65%, with half those deaths occurring within the first two days. The location and size of the bleeding, as well as the age, health, and level of consciousness of the victim, all factor into the likelihood of survival. If the victim was on a blood-thinning medication, the outcome is likely to be worse.

It is difficult to say how often people with intracerebral hemorrhage return to a good level of independent functioning. Some people believe that because the blood displaces brain tissue rather than directly robbing it of oxygen, people who survive a hemorrhagic stroke may actually have relatively good outcomes compared to people with ischemic strokes of similar size.

However, it's hard to be certain. Recent estimates of a relatively good outcome after intracerebral hemorrhage range from 12% to 39%. More information is clearly needed.

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2 Sources
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  1. National Institute of Neurological Disorders and Stroke.

    Moyamoya disease information page. Updated March 27, 2019.

  2. Rymer MM. Hemorrhagic stroke: Intracerebral hemorrhageMo Med. 2011;108(1):50-54.

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