Hemorrhage - intracerebral (deep)

Alternative names
Deep intracerebral hemorrhage; Intracranial bleed

Definition
Deep intracerebral hemorrhage is a type of stroke caused by bleeding within the deep structures of the brain (thalamus, basal ganglia, pons, and cerebellum).

Causes, incidence, and risk factors

Intracerebral hemorrhage can affect any person regardless of age, sex, or race, though it is more common in older people. Bleeding can occur in any part of the brain, and blood may accumulate in the tissues or in the subarachnoid space (space between the brain and the membranes covering the brain, the meninges).

Bleeding may be isolated to part of one cerebral hemisphere (lobar intracerebral hemorrhage) or may occur in other brain structures such as the thalamus, basal ganglia, pons, or cerebellum. Intracerebral hemorrhage that is not caused by trauma most commonly occurs in the basal ganglia.

Intracerebral hemorrhage can be caused by Head injury (trauma), bleeding into a tumor, abnormalities of the blood vessels (cerebral aneurysm or angioma -tumors involving the blood vessels) or an abnormality in blood clotting.

When it is not caused by one of these conditions, intracerebral hemorrhage is most commonly associated with high blood pressure (hypertensive intracerebral hemorrhage). In some cases, no cause can be found.

Bleeding in the brain irritates the brain tissues, causing swelling (cerebral edema). It may collect into a mass (hematoma). Both cerebral edema and the presence of a hematoma within the brain will place increasing pressure on the brain tissues and eventually destroy them. Symptoms vary depending on the extent of damage and the location of the bleed.

Risk factors for intracerebral hemorrhage, in addition to the causative disorders, include the following:

     
  • Various blood or bleeding disorders       o Disseminated intravascular coagulation (DIC)       o Hemophilia       o Sickle cell anemia       o Leukemia       o Decreased blood platelets  
  • Use of aspirin or anticoagulant medications (blood thinners)  
  • Liver disease (associated with increased bleeding risk)

Symptoms

     
  • Headache       o May occur when lying flat       o May cause patient to awaken from sleep       o May increase with change in position       o Often starts suddenly       o May increase with bending, straining, and coughing  
  • Nausea or vomiting  
  • Change in alertness (level of consciousness)       o Apathetic, withdrawn       o Sleepy, lethargic, somnolent, stuporous       o Unconscious, comatose  
  • Decreased vision  
  • Loss of all or part of vision  
  • Sensation changes, usually on only one side of the body       o Decreased sensation       o Numbness or tingling       o Abnormal sensations  
  • Difficulty speaking or understanding others  
  • Difficulty swallowing  
  • Difficulty writing or reading  
  • Movement changes, usually on only one side of the body       o Weakness of any body part       o Difficulty moving any body part       o Loss of fine motor skills  
  • Loss of coordination  
  • Loss of balance  
  • Seizure

The symptoms vary depending on the location of the bleed and the amount of brain tissue affected. Symptoms most commonly develop suddenly, without warning, often during activity. They may be episodic (occurring and then stopping) or develop in a progressively worsening manner.

Signs and tests

Neurological examination may indicate increased intracranial pressure or decreases in specific brain functions. The specific pattern of symptoms and function changes may indicate which of the deep brain tissues are affected. For example, sudden nausea, vomiting, loss of balance, headache, and rapid decrease in consciousness may indicate a bleed in the cerebellum or brainstem.

Eye examination may show swelling of the optic nerve from pressure in the brain, or there may be changes in eye movement. Abnormal reflexes may be present.


Tests to determine the cause of bleeding include:

     
  • CBC  
  • Platelet count  
  • Bleeding time  
  • Prothrombin time (PT) or partial thromboplastin time (PTT)  
  • Liver function tests  
  • Kidney function tests

Deep intracerebral hemorrhage may be confirmed, and the exact location and amount of bleeding determined by:

     
  • Head CT (may be preferred if bleed is less than 48 hours old)  
  • MRI of head  
  • Angiogram (may be necessary)

Treatment

Deep intracerebral hemorrhage is a severe condition requiring prompt medical attention - even if symptoms are episodic. It can develop quickly into a life-threatening situation.

Treatment goals include life support measures and control of symptoms. Treatment varies depending on the specific location, extent, and cause of the bleeding.

Surgical removal of hematomas may be appropriate, especially if there is a hematoma in the cerebellum. Surgical repair or removal of structures causing the bleed (repair of cerebral aneurysm, Arteriovenous malformation) may be appropriate in some cases.

Medicines used may include corticosteroids or diuretics to reduce swelling, anticonvulsants to control seizures, medicine to control pain, and others.

Other treatments may be recommended, depending on the condition of the person and the symptoms that develop.

Expectations (prognosis)

The outcome is highly variable. Prognosis depends on the degree of swelling and size of the hematoma. Death may occur quickly despite prompt medical treatment.

Recovery may occur completely or with any level of permanent loss of brain functions. Medications, surgery, or other treatments may have severe side effects.

Complications

     
  • Permanent loss of any brain function       o Loss of vision       o Loss of movement of one or all extremities       o Loss of speaking ability       o Loss of eating or swallowing ability       o Loss of cognitive function  
  • Complications of surgery  
  • Side effects of medications used to treat the disorder  
  • Hydrocephalus, especially if blood is in the ventricles.

Calling your health care provider
Call your health care provider if severe headache with nausea, vomiting, decreased vision, numbness, or tingling occurs.

Go to the emergency room or call 911 if other symptoms of deep intracerebral hemorrhage develop. Emergency symptoms include difficulty breathing, seizures, loss of ability to move or swallow, sudden loss of sensations, sudden change in mental state, and loss of consciousness.

Prevention

Treatment or control of causative and risk-related disorders may reduce the risk of developing intracerebral hemorrhage. High blood pressure should be treated as appropriate. Do not stop taking medications unless advised to do so by the health care provider.

Minimize the risk of Head injury by using appropriate safety equipment and safety precautions in sports, recreation, and work. For example, use hard hats, bicycle or motorcycle helmets, and seat belts. Do not dive into water if you do not know the depth of the water or if there may be rocks under the surface.

If you are taking a blood thinner (such as coumadin), follow your doctor’s instructions on how to take the medicine and when to have blood tests for monitoring the medication.

Johns Hopkins patient information

Last revised: December 3, 2012
by Levon Ter-Markosyan, D.M.D.

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All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.