Lobar intracerebral hemorrhage

Alternative names
Hemorrhage - intraparenchymal; Hemorrhage - intracerebral (lobar)

Definition

Lobar intracerebral hemorrhage involves bleeding in the brain. The bleeding (hemorrhage) is isolated to one specific area of the brain, somewhere in the white matter portion of the cerebrum. (The cerebrum is the large part of the brain consisting of two hemispheres of 4 lobes each.)

Causes, incidence, and risk factors

Lobar intracerebral hemorrhage may be caused by a traumatic brain injury or abnormalities of the blood vessels, such as aneurysm, Arteriovenous malformation, or angioma (tumors involving blood vessels). When it is not caused by trauma, lobar intracerebral hemorrhage can be considered a type of stroke.

A lobar hemorrhage can be associated with amyloid deposits in the blood vessels (amyloid angiopathy). In some patients, using blood thinners may result in a lobar hemorrhage. Brain tumors or, in rare cases, infections can also lead to bleeding in the brain. In some cases, no cause can be found.

Lobar hemorrhages are also associated with the following:

     
  • Various blood or bleeding disorders, such as disseminated intravascular coagulation, hemophilia, sickle cell anemia, and leukemia.  
  • Decreased levels of blood platelets  
  • Use of aspirin or blood thinners  
  • Liver disease (associated with increased bleeding risk)  
  • Cerebral amyloid  
  • Some autoimmune disorders

Symptoms
Symptoms usually develop suddenly, without warning, often during activity. The symptoms vary, depending on the location of the bleeding and the amount of brain tissue affected. Possible symptoms include the following:

     
  • A change in alertness or level of consciousness (this is the first symptom in about 50% of people, including children)       o Apathetic, withdrawn       o Sleepy, lethargic, somnolent, stuporous       o Unconscious, comatose       o Dementia before the bleed occurs (rare in children) from cerebral amyloid  
  • Vomiting       o Occurs frequently       o Often described as occurring without nausea       o Occurs more frequently in the morning  
  • Possible headache       o May develop suddenly       o May awaken the patient from sleep       o Increased with change in position       o Increased with bending, straining, coughing

The symptoms of localized damage may develop:

     
  • Loss of all or part of vision  
  • Sensation changes       o Decreased sensation       o Numbness or tingling       o Abnormal sensations  
  • 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/clumsiness  
  • Loss of coordination  
  • Loss of balance  
  • Seizure

Other symptoms:

     
  • Stiff neck  
  • Aching of neck, shoulders  
  • Pain when bending neck

Additional symptoms that may be associated with this condition:

     
  • Loss of muscle function or feeling  
  • Dysfunctional movement  
  • Facial paralysis  
  • Eyelid drooping

Signs and tests

A neurological examination may indicate increased intracranial pressure or decreases in brain function. The patient’s symptoms and brain function changes may indicate where the bleeding is specifically located. Some patients with mild hemorrhages may only have a headache.

The physical examination may reveal swelling of the optic nerve from increased pressure in the brain. There may be changes in eye movement, abnormal reflexes, decreased vision, loss of movement or coordination, or inability to feel sensations properly.

Tests to determine the amount and cause of bleeding may include:

     
  • 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 determined by:

     
  • Head CT scan (preferred if bleeding is less than 48 hours old)  
  • Head MRI

Angiography of the head may be necessary in some cases to determine if there is an aneurysm or Arteriovenous malformation present.

Treatment

The treatment depends on the specific location, extent, and cause of the bleeding. Treatment goals may include lifesaving interventions such as intubation and hyperventilation (when a breathing tube is inserted and the person is forced to breathe rapidly to reduce pressure in the brain).

If the bleed is small and does not cause increased pressure within the brain, treatment may be conservative and focus on controlling the symptoms.

Surgical removal of hematomas (areas of pooled blood) may be appropriate in some cases. Surgical repair of structures causing the bleed, such as repair of an aneurysm or Arteriovenous malformation, may be appropriate in some cases.

Medication may be needed to reduce brain swelling. Anticonvulsants can be used to control seizures, analgesics may be needed to control pain, and other medications may be required for symptoms particular to the area affected.

If a bleeding disorder is present, medications or blood products may be needed to control it.

Expectations (prognosis)

The long-term outcome is highly variable. 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 treatments for this condition may have severe side effects.

Complications

Blood irritates the tissues of the brain and may cause swelling (cerebral edema). Blood collects into a mass (hematoma). Both cerebral edema and the presence of a hematoma within the brain will put increasing pressure on the tissues of the brain and can destroy those tissues.

Blood may collect in the subarachnoid space and irritate the membranes covering the brain (meningeal irritation). Complications will vary depending on the extent of damage and the location of the bleed:

     
  • Hydrocephalus (water on the brain)  
  • Permanent loss of any brain function  
  • Side effects of medications used to treat the disorder  
  • Complications of surgery  
  • Seizure disorder

Calling your health care provider

Go to the emergency room or call 911 if anyone has symptoms of a brain hemorrhage.

Any type of intracerebral hemorrhage is a severe condition (“brain attack”) requiring prompt medical attention. It may develop quickly into a life-threatening situation.

Prevention

Treatment and controlling any risk-related disorders may reduce the risk of developing a brain hemorrhage.

High blood pressure should be treated as appropriate. Do not stop taking prescription medications unless advised to do so by your health care provider!Abruptly stopping such medications could lead to this disorder.

If you take blood thinners, your medication dosage needs to be monitored by blood tests, as directed by your health care provider, to make sure that the medications aren’t making bleeding too likely and increasing your risk of hemorrhage.

Johns Hopkins patient information

Last revised: December 7, 2012
by Mamikon Bozoyan, M.D.

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