Alternate Names: Intracranial hemorrhage; Hemorrhage - intracerebral

Causes and Risks: Internal bleeding can occur in any part of the brain, and blood may accumulate in the tissues or in the space between the brain and the membranes covering the brain (subarachnoid space). It may be isolated to part of one cerebral hemisphere (lobar intracerebral hemorrhage) or occur in other brain structures, such as the thalamus, basal ganglia, pons, or cerebellum (deep intracerebral hemorrhage).

Intracerebral hemorrhage may be caused by trauma (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). Blood collects into a mass (hematoma). Both cerebral edema and the presence of a hematoma within the brain will put increasing pressure on the brain tissues of the brain and destroy them.

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. They may occasionally develop in a stepwise, episodic manner or in a progressive manner.

The risks for intracerebral hemorrhage, in addition to the causative disorders, include various blood and bleeding disorders (disseminated intravascular coagulation, hemophilia, sickle cell anemia, leukemia, and 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 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 or IVH. This occurs in the first day or so of life and is usually unpreventable. The outcome is variable (depending on the severity of bleed) and ranges from a normal child to severe disability. Diagnosis is by ultrasound and usually done in an intensive care nursery.

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 the health care provider.

Symptoms:

• Headache
  • May occur when flat, and awaken person from sleep
  • May increase with change in position
  • May increase with bending, straining, and coughing
• Nausea, vomiting
• Change in alertness (level of consciousness)
  • Apathetic, withdrawn
  • Sleepy, lethargic, somnolent, stuporous
  • Unconscious, comatose
• Vision changes
  • Any change in vision
  • Decreased vision, loss of all or part of vision
  • Eyes, pupils different size
  • Eye movements, uncontrollable
  • Eye lid drooping
• Sensation changes
  • Decreased sensation
  • Numbness, tingling
  • Abnormal sensations
  • Facial paralysis
• 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
  • Hand tremor
• Loss of coordination
• Loss of balance
• Seizure or spell
• Abnormal taste

Signs and Tests: Neuromuscular 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 from 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 amount and cause of bleeding may include:

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

• Head CT scan ( preferred if the bleed is less than 48 hours old)
• Head MRI
• Angiography of the head (if symptoms allow enough time) to determine if there is an aneurysm or arteriovenous malformation present

Treatment: Intracerebral hemorrhage is a severe condition requiring prompt medical attention even if symptoms are episodic or progressive. 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, analgesics to control pain, or others.

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

Other treatments may be appropriate.

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

Complications:

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

Go to the emergency room or call the local emergency number (such as 911) if symptoms indicate intracerebral hemorrhage. This is a serious condition.

Emergency symptoms include:

• Difficulty breathing
• Seizures
• Loss of consciousness
• Inability to speak or swallow