Intracerebral Hemorrhage

Overview

Intracerebral hemorrhage (ICH) is a devastating type of stroke that occurs when blood vessels within the brain tissue rupture and bleed into the surrounding brain parenchyma. This condition represents approximately 10-15% of all strokes but accounts for a disproportionately high percentage of stroke-related deaths and severe disabilities. Unlike ischemic strokes, which are caused by blocked blood vessels, ICH results from the rupture of blood vessels, leading to direct brain tissue damage from both the bleeding itself and the resulting increase in intracranial pressure.

The bleeding in ICH can occur in various parts of the brain, with the most common locations being the basal ganglia, thalamus, cerebellum, and brainstem. The size and location of the hemorrhage significantly influence the patient's symptoms, prognosis, and potential for recovery. Large hemorrhages or those in critical brain areas can be immediately life-threatening, while smaller bleeds may cause more subtle neurological deficits that can still significantly impact quality of life.

ICH typically affects older adults, with the highest incidence occurring in people over 55 years of age. The condition is more common in men than women and shows significant racial and ethnic disparities, with higher rates among African Americans, Hispanics, and Asians compared to Caucasians. These disparities are largely attributed to differences in the prevalence of risk factors such as hypertension, diabetes, and genetic predisposition.

The prognosis for ICH varies widely depending on factors such as the size and location of the hemorrhage, the patient's age and overall health, and how quickly medical treatment is received. While ICH has traditionally been associated with poor outcomes, advances in emergency medical care, neurocritical care, and rehabilitation have improved survival rates and functional outcomes for many patients. Early recognition of symptoms and immediate medical intervention are crucial for optimizing outcomes and minimizing long-term disability.

Symptoms

Intracerebral hemorrhage symptoms typically develop suddenly and can rapidly worsen, making immediate medical attention critical.

Primary Symptoms

Neurological Symptoms

Motor Symptoms

• Hemiparesis/Hemiplegia: Weakness or paralysis on one side of body
• Facial droop: Asymmetrical facial weakness
• Arm/leg weakness: Inability to lift or move limbs
• Gait disturbances: Difficulty walking or balance problems
• Coordination problems: Loss of fine motor control

Sensory Symptoms

• Numbness: Loss of sensation on affected side
• Tingling: Abnormal sensations
• Loss of position sense: Difficulty knowing limb position
• Sensory neglect: Ignoring one side of body or space

Cognitive and Speech Symptoms

• Aphasia: Difficulty speaking or understanding language
• Dysarthria: Slurred or difficult speech
• Confusion: Disorientation or altered mental state
• Memory problems: Difficulty with recall or recognition
• Attention deficits: Inability to concentrate or focus
• Executive dysfunction: Problems with planning and decision-making

Visual Symptoms

• Visual field defects: Loss of portions of visual field
• Double vision: Diplopia
• Blurred vision: Decreased visual acuity
• Visual neglect: Ignoring visual information from one side
• Complete vision loss: Blindness in severe cases

Signs of Increased Intracranial Pressure

• Severe headache: Progressively worsening
• Nausea and vomiting: Often projectile vomiting
• Altered consciousness: Drowsiness, confusion, coma
• Pupillary changes: Unequal or non-reactive pupils
• Bradycardia: Slow heart rate
• Hypertension: Elevated blood pressure
• Irregular breathing: Abnormal respiratory patterns

Location-Specific Symptoms

Basal Ganglia Hemorrhage

• Contralateral hemiparesis
• Sensory loss
• Gaze deviation
• Aphasia (if dominant hemisphere)
• Neglect (if non-dominant hemisphere)

Thalamic Hemorrhage

• Severe sensory loss
• Hemiparesis
• Vertical gaze palsy
• Altered consciousness
• Memory impairment

Cerebellar Hemorrhage

• Severe headache
• Nausea and vomiting
• Ataxia (loss of coordination)
• Dizziness
• Difficulty walking
• Rapid deterioration possible

Brainstem Hemorrhage

• Rapid loss of consciousness
• Quadriplegia
• Cranial nerve palsies
• Breathing difficulties
• Often fatal

Emergency Warning Signs

• Sudden severe headache
• Sudden weakness or numbness
• Sudden speech problems
• Sudden vision problems
• Sudden severe dizziness
• Loss of consciousness
• Seizure activity
• Vomiting with neurological symptoms

Causes

Intracerebral hemorrhage can result from various underlying conditions that weaken blood vessels or increase bleeding risk.

Primary Causes

Hypertension

• Most common cause: Accounts for 50-60% of ICH cases
• Chronic hypertension: Weakens small blood vessels over time
• Microangiopathy: Damage to small brain arteries
• Lipohyalinosis: Vessel wall thickening and weakening
• Acute blood pressure spikes: Can trigger rupture

Cerebral Amyloid Angiopathy (CAA)

• Amyloid deposits: Accumulation in blood vessel walls
• Age-related: More common in elderly patients
• Lobar hemorrhages: Typically affects superficial brain areas
• Recurrent bleeding: High risk of repeat hemorrhages
• Associated with Alzheimer's: Common in dementia patients

Vascular Malformations

• Arteriovenous malformations (AVMs): Abnormal vessel connections
• Cavernous malformations: Clusters of abnormal blood vessels
• Arteriovenous fistulas: Direct artery-to-vein connections
• Venous angiomas: Abnormal venous drainage patterns
• Capillary telangiectasias: Dilated capillary networks

Coagulation Disorders

Anticoagulant-Related

• Warfarin therapy: Increased bleeding risk
• Novel anticoagulants: DOACs (dabigatran, rivaroxaban, etc.)
• Heparin administration: Therapeutic or prophylactic use
• Over-anticoagulation: Excessive anticoagulation levels

Platelet Disorders

• Thrombocytopenia: Low platelet count
• Antiplatelet medications: Aspirin, clopidogrel
• Platelet dysfunction: Qualitative platelet defects
• Bone marrow disorders: Affecting platelet production

Tumors and Neoplasms

• Primary brain tumors: Glioblastoma, oligodendroglioma
• Metastatic tumors: Melanoma, lung, kidney, thyroid cancer
• Vascular tumors: Highly vascularized neoplasms
• Tumor necrosis: Death of tumor tissue causing bleeding
• Treatment-related: Radiation or chemotherapy effects

Drug-Related Causes

Illicit Drugs

• Cocaine: Acute hypertension and vasoconstriction
• Amphetamines: Blood pressure elevation
• Heroin: Associated with infectious complications
• Alcohol: Acute intoxication effects

Therapeutic Medications

• Thrombolytics: tPA, streptokinase
• Sympathomimetics: Decongestants, stimulants
• Dietary supplements: Ginkgo, ginseng, fish oil

Infectious Causes

• Bacterial endocarditis: Septic emboli
• Mycotic aneurysms: Infected vessel walls
• Cerebral abscess: With rupture into brain tissue
• Meningitis: Secondary vascular complications
• Viral encephalitis: Vessel inflammation and bleeding

Systemic Conditions

• Liver disease: Coagulopathy from liver dysfunction
• Kidney disease: Uremic bleeding tendency
• Blood disorders: Leukemia, aplastic anemia
• Vasculitis: Inflammatory vessel disease
• Connective tissue disorders: Affecting vessel integrity

Traumatic Causes

• Head trauma: Blunt or penetrating injuries
• Contusions: Brain bruising with bleeding
• Diffuse axonal injury: Shearing forces
• Birth trauma: In newborns
• Shaken baby syndrome: Abusive head trauma

Risk Factors

Multiple factors can increase the risk of developing intracerebral hemorrhage:

Major Risk Factors

• Hypertension: Most important modifiable risk factor
• Advanced age: Risk increases significantly after age 55
• Male gender: Higher incidence in men
• Race/ethnicity: Higher rates in African Americans, Hispanics, Asians
• Previous stroke: History of any type of stroke
• Anticoagulant use: Therapeutic anticoagulation

Medical Risk Factors

• Diabetes mellitus
• Heart disease
• Atrial fibrillation
• Kidney disease
• Liver disease
• Blood disorders
• Brain tumors
• Vascular malformations

Lifestyle Risk Factors

• Heavy alcohol consumption
• Illicit drug use (cocaine, amphetamines)
• Smoking
• Physical inactivity
• Poor diet
• Obesity
• High stress levels

Medication-Related Risks

• Warfarin and other anticoagulants
• Antiplatelet medications
• Thrombolytic therapy
• Certain supplements
• Sympathomimetic drugs

Diagnosis

Rapid diagnosis of intracerebral hemorrhage is crucial for appropriate treatment and improved outcomes.

Emergency Assessment

• FAST assessment: Face, Arms, Speech, Time
• Vital signs: Blood pressure, heart rate, temperature
• Neurological examination: Level of consciousness, focal deficits
• Glasgow Coma Scale: Assess consciousness level
• NIH Stroke Scale: Quantify stroke severity

Imaging Studies

CT Scan

• First-line imaging: Rapid detection of hemorrhage
• Hyperdense lesion: Acute blood appears bright
• Location assessment: Determines hemorrhage site
• Size measurement: Volume calculation
• Mass effect: Midline shift, herniation

CT Angiography (CTA)

• Identify vascular causes
• Detect aneurysms or AVMs
• Assess spot sign (active bleeding)
• Evaluate vessel anatomy

MRI

• Better soft tissue contrast: Detailed brain imaging
• Gradient echo sequences: Detect old hemorrhages
• Diffusion-weighted imaging: Assess ischemic areas
• Vascular imaging: MR angiography

Laboratory Tests

• Complete blood count
• Coagulation studies (PT/INR, PTT)
• Platelet count and function
• Blood glucose
• Electrolytes
• Liver function tests
• Toxicology screen

Treatment Options

Treatment of intracerebral hemorrhage focuses on stabilizing the patient, managing complications, and preventing further bleeding.

Emergency Management

• Airway protection: Intubation if needed
• Blood pressure control: Target systolic <140-180 mmHg
• ICP monitoring: If elevated intracranial pressure
• Coagulation reversal: If on anticoagulants
• Seizure management: Antiepileptic drugs if seizures

Medical Management

• Blood pressure medications
• Osmotic therapy for increased ICP
• Temperature control
• Glucose management
• DVT prophylaxis
• Nutrition support

Surgical Options

• Craniotomy: Open surgical removal
• Minimally invasive surgery: Endoscopic or stereotactic
• External ventricular drain: For hydrocephalus
• Decompressive craniectomy: For mass effect

Rehabilitation

• Physical therapy
• Occupational therapy
• Speech therapy
• Cognitive rehabilitation
• Social work support

Prevention

Many risk factors for intracerebral hemorrhage can be modified to reduce risk:

Blood Pressure Management

• Regular monitoring
• Medication compliance
• Lifestyle modifications
• Target BP <130/80 mmHg

Lifestyle Modifications

• Healthy diet
• Regular exercise
• Weight management
• Smoking cessation
• Moderate alcohol consumption
• Avoid illicit drugs

Medical Management

• Diabetes control
• Cholesterol management
• Careful anticoagulation monitoring
• Regular medical check-ups

When to See a Doctor

Intracerebral hemorrhage is a medical emergency requiring immediate attention.

Call 911 Immediately for:

• Sudden severe headache
• Sudden weakness or numbness
• Sudden speech problems
• Sudden vision loss
• Loss of consciousness
• Seizures
• Severe dizziness with neurological symptoms

FAST Signs of Stroke

• Face: Facial droop or asymmetry
• Arms: Arm weakness or drift
• Speech: Slurred or garbled speech
• Time: Time to call emergency services

Related Conditions

Frequently Asked Questions