Hypertensive intracerebral hemorrhage

Alternative names
Hemorrhage - intracerebral (hypertensive)

Definition
Hypertensive intracerebral hemorrhage is bleeding in the brain caused by high blood pressure.

Causes, incidence, and risk factors

Intracerebral hemorrhage can affect any person, regardless of age, sex, or race, but it is most common in older individuals.

Hypertensive intracerebral hemorrhage is caused by chronic high blood pressure (hypertension). When blood pressure has remained high for a significant period of time, blood vessel walls can change in a process called lipohyalinosis. This can lead to blockage of the vessels and leakage of blood into the brain as the constant pressure wears away at the vessels’ walls.

Intracerebral bleeding associated with hypertension most commonly occurs in the tissues of the basal ganglia, pons, cerebellum, and deep white matter of the brain. Blood irritates the brain tissues, causing swelling (cerebral edema).

The blood collects into a mass (hematoma). Both the swelling of the brain tissues and the presence of a hematoma within the brain put increasing pressure on brain tissue and can eventually destroy it.

Bleeding may occur into the ventricles of the brain or into the subarachnoid space (the space between the brain and the meninges, the membranes that cover the brain), causing symptoms of meningeal irritation.

Symptoms

Symptoms vary depending on the extent of damage and the location of the bleeding. Symptoms most commonly develop suddenly, without warning, often during activity.

They may occasionally develop in a stepwise, episodic manner or in a progressive manner. There is a rapid loss of function(s) on one side of the body. These symptoms can be the same as when there is insufficient circulation to the brain (stroke).

Symptoms can include the following:

     
  • Vision changes       o Any change in vision       o Loss of vision off to one side       o Decreased vision  
  • Sensation changes       o Numbness, tingling       o Decreased sensation       o Abnormal sensations  
  • Movement changes       o Weakness of any body part       o Difficulty moving any body part       o Loss of fine motor skills  
  • Difficulty speaking or understanding others  
  • Difficulty swallowing  
  • Difficulty reading or writing  
  • Loss of coordination  
  • Loss of balance  
  • Seizure  
  • Headache       o When lying flat       o May awaken from sleep       o Increases with change in position, bending, straining, coughing  
  • Nausea, vomiting  
  • Decreased consciousness       o Apathetic, withdrawn       o Sleepy, lethargic, somnolent, stuporous       o Unconscious, comatose

Signs and tests

Neurologic examination may indicate increased intracerebral pressure, such as swelling of the optic nerve or changes in eye movement. Localized abnormalities in brain function are detected by observing abnormal reflexes or movement.

The specific pattern of function changes may indicate the location of the problem within the brain. However, an image of the brain (CT scan or MRI) is necessary to prove the condition is due to intracerebral hemorrhage.

In order to diagnose the hemorrhage as a hypertensive hemorrhage, there must be some evidence of high blood pressure. Often the blood pressure is still very elevated when the patient is examined. Other times, there are other findings on examination or tests to suggest hypertension, such as abnormal blood vessels in the eyes or abnormal kidney function.

Tests to determine the amount and cause of bleeding include:

     
  • CBC  
  • Platelet count  
  • Bleeding time  
  • Prothrombin time  
  • Partial thromboplastin time  
  • Liver function tests  
  • Kidney function tests  
  • Angiography of the head (if symptoms allow enough time to perform this test) - reveals any aneurysm or Arteriovenous malformation present

Intracerebral hemorrhage can be confirmed, and the location and amount of bleeding determined, by the following:

     
  • Head CT scan (preferred if the hemorrhage began less than 48 hours earlier)  
  • Head MRI

Treatment
Treatment goals include life support measures and control of symptoms.

Surgical removal of the hematoma may be appropriate, especially if there is a hematoma in the base of the brain (cerebellum). If bleeding blocks the flow of spinal fluid, a shunt or drain in the brain may be recommended in some cases.

Medications include antihypertensive medications to control blood pressure; corticosteroids such as hydrocortisone and diuretics to drain fluid from the body to reduce brain swelling; anticonvulsants to control seizures; and analgesics to control pain.

Expectations (prognosis)
The probable outcome is highly variable and depends on the size and location of the bleed. Recovery can occur completely, or with any level of permanent loss of brain function. Medications, surgery and treatments can have severe side effects. Death can occur rapidly despite prompt medical attention.

Complications

     
  • Permanent loss of any brain function  
  • Seizures  
  • Side effects of medications and treatments  
  • Complications of surgery

Calling your health care provider

Intracerebral hemorrhage is a life-threatening condition requiring immediate emergency medical attention.

Go to the emergency room or call the local emergency number (such as 911) if symptoms of hypertensive intracerebral hemorrhage occur. Emergency symptoms include difficulty breathing, seizures, loss of consciousness, inability to speak and swallowing difficulties, numbness or clumsiness on one side of the body, slurred speech, or confusion.

Prevention
Treatment and control of disorders that can bring on intracerebral hemorrhage will reduce the risk. High blood pressure should be treated as appropriate. DO NOT stop taking medications unless advised to do so by your health care provider!

Johns Hopkins patient information

Last revised: December 8, 2012
by Brenda A. Kuper, M.D.

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