Hypertensive hemorrhage

Alternative names
Intracranial hemorrhage; Hemorrhage - intracerebral; Intracerebral hemorrhage

Definition
An intracerebral hemorrhage is bleeding in the brain caused by the rupture of a blood vessel within the head.

Causes, incidence, and risk factors

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  • Change in alertness (level of consciousness)       o Apathetic, withdrawn       o Sleepy, lethargic, somnolent, stuporous       o Unconscious, comatose  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

Signs and tests

Neurologic examination may indicate increased intracranial pressure or focal neurologic deficits (decreases in brain function). The specific pattern of symptoms and function changes may indicate the location of the intracerebral hemorrhage.

Eye examination may show optic nerve swelling caused by increased pressure in the brain, or there may be changes in eye movement. Abnormal reflexes may be present, or there may be an abnormal extent of normal reflexes.

Tests to determine the cause of bleeding may include:

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

Intracerebral hemorrhage may be confirmed, and the location and amount of bleeding can be determined by these tests:

     
  • Head CT scan (preferred if the bleed is less than 48 hours old)  
  • Head MRI or MRA  
  • Conventional cerebral angiography or spiral CT scan angiography of the head (if symptoms allow enough time) to determine whether an aneurysm or Arteriovenous malformation (abnormal collection of blood vessels) is present

Treatment
An intracerebral hemorrhage is a severe condition requiring prompt medical attention even if symptoms are episodic (occurring occasionally, then disappearing). It may develop quickly into a life-threatening situation.

Treatment goals include lifesaving interventions, supportive 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 of structures causing the bleed (repair of 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.

Blood, blood products, intravenous fluids, or medications may be appropriate to counteract bleeding and loss of blood volume.

Expectations (prognosis)
The outcome varies highly. Death may occur rapidly despite prompt medical treatment. Recovery may occur completely or with a permanent loss of some brain functions. Medications, surgery or treatments for this condition can have severe side effects.

Complications

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

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

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

Johns Hopkins patient information

Last revised: December 3, 2012
by Gevorg A. Poghosian, Ph.D.

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