Alternate Names: Hemorrhage - intraparenchymal; Hemorrhage - intracerebral (lobar)

Causes and Risks:

Lobar intracerebral hemorrhage occurs when there is bleeding in the superficial (surface) white matter of the cerebrum (part of the brain).

It may be caused by trauma (brain injury) or abnormalities of the blood vessels, such as aneurysm, arteriovenous malformation (AVM), or angioma (tumors involving blood vessels). In some cases, no cause can be found. The disorder is likely to be associated with amyloid deposits in the blood vessels (amyloid angiopathy).

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 destroy those tissues.

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

Risks for lobar intracerebral hemorrhage, in addition to the causative disorders, include various blood or bleeding disorders (disseminated intravascular coagulation; hemophilia; sickle cell anemia; leukemia; (decreased levels of blood platelets) use of aspirin or anticoagulant medications "blood thinners"; liver disease (which is associated with increased bleeding risk); and cerebral amyloid, infection, and autoimmune disorders.

Prevention: Treatment and 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 prescription medications unless advised to do so by the health care provider.

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

• Change in alertness (level of consciousness)
  • The first symptom in about 50% of people
  • In children, a change in the level of alertness
  • Apathetic, withdrawn
  • Sleepy, lethargic, somnolent, stuporous
  • Unconscious, comatose
  • If cerebral amyloid is present, some individuals are demented before the bleed occurs (this is rare in children)
• Vomiting
  • Occurs frequently
  • Often described as occurring without nausea
  • Occurs more frequently in the morning
• Possible headache
  • When flat, may awaken from sleep
  • Increased with change in position
  • Increased with bending, straining, coughing, etc.

Symptoms of focal (localized) damage may develop:

• Vision changes
  • Any change in vision
  • Decreased vision, loss of all or part of vision
• Sensation changes
  • Decreased sensation
  • Numbness, tingling
  • Abnormal sensations
• Difficulty speaking or understanding speech
• Difficulty swallowing
• Difficulty writing or reading
• Movement changes
  • Weakness of any body part
  • Difficulty moving any body part
  • Loss of fine motor skills
• Loss of coordination
• Loss of balance
• Seizure or spell

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

• Muscle function or feeling loss
• Movement, dysfunctional
• Facial paralysis
• Eyelid drooping

Signs and Tests:

Neurological examination may indicate meningeal irritation, 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 lobar intracerebral hemorrhage.

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

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

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

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

Treatment: The treatment is variable depending on the specific location, extent, and cause of the bleeding. Treatment goals may include lifesaving interventions such as intubation and hyperventilation. (A breathing tube is inserted, and the person is forced to breath rapidly. This reduces pressure in the brain.) Treatment goals may also include supportive measures or control of symptoms.

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

Surgical removal of hematomas may be appropriate in some cases. Surgical repair of structures causing the bleed (repair of aneurysm, arteriovenous malformation, etc.) may be appropriate in some cases.

Medicines may be needed to reduce brain swelling. Anticonvulsants may be needed to control seizures, analgesics may be needed to control pain, or other medications may be needed.

Prognosis: The probable outcome is highly variable. Death may occur rapidly despite prompt medical treatment. Recovery may occur, completely or with any level of permanent loss of brain functions. Medications, surgery, or treatments may have severe side effects.

Complications:

• Hydrocephalus
• Permanent loss of any brain function
• Side effects of medications used to treat the disorder
• Complications of surgery

Call your health care provider if symptoms indicate lobar intracerebral hemorrhage. Intracerebral hemorrhage is a severe condition requiring prompt medical attention. It may develop quickly into a life-threatening situation.

Go to the emergency room or call the local emergency number (such as 911) if symptoms include difficulty breathing, seizures, loss of consciousness, and inability to speak or swallow.