Type of intracranial bleeding that occurs within the brain tissue itself
Medical condition
Intracerebral hemorrhage
|
---|
Other names
| Cerebral haemorrhage, cerebral hemorrhage, intra-axial hemorrhage, cerebral hematoma, cerebral bleed, brain bleed, hemorrhagic stroke
|
---|
|
CT scan
of a spontaneous intracerebral bleed, leaking into the
lateral ventricles
|
Specialty
| Neurosurgery
|
---|
Symptoms
| Headache
, one-sided numbness, weakness, tingling, or paralysis, speech problems, vision or hearing problems, dizziness or lightheadedness or vertigo, nausea/vomiting, seizures,
decreased level
or
total loss of consciousness
,
neck stiffness
, memory loss, attention and coordination problems, balance problems,
fever
,
shortness of breath
(when bleed is in the brain stem)
[1]
[2]
|
---|
Complications
| Coma
,
persistent vegetative state
,
cardiac arrest
(when bleeding is severe or in the brain stem),
death
|
---|
Causes
| Brain trauma
,
aneurysms
,
arteriovenous malformations
,
brain tumors
,
hemorrhagic conversion of ischemic stroke
[1]
|
---|
Risk factors
| High blood pressure
,
diabetes
,
high cholesterol
,
amyloidosis
,
alcoholism
,
low cholesterol
,
blood thinners
,
cocaine
use
[2]
|
---|
Diagnostic method
| CT scan
[1]
|
---|
Differential diagnosis
| Ischemic stroke
[1]
|
---|
Treatment
| Blood pressure
control, surgery,
ventricular drain
[1]
|
---|
Prognosis
| 20% good outcome
[2]
|
---|
Frequency
| 2.5 per 10,000 people a year
[2]
|
---|
Deaths
| 44% die within one month
[2]
|
---|
Intracerebral hemorrhage
(
ICH
), also known as
hemorrhagic stroke
, is a sudden bleeding into
the tissues of the brain
(i.e. the parenchyma), into its
ventricles
, or into both.
[3]
[4]
[1]
An ICH is a type of bleeding within the
skull
and one kind of
stroke
(ischemic stroke being the other).
[3]
[4]
Symptoms can vary dramatically depending on the severity (how much blood), acuity (over what timeframe), and location (anatomically) but can include
headache
,
one-sided weakness
, numbness, tingling, or
paralysis
, speech problems, vision or hearing problems, memory loss, attention problems, coordination problems, balance problems,
dizziness
or
lightheadedness
or
vertigo
, nausea/vomiting, seizures,
decreased level of consciousness
or
total loss of consciousness
,
neck stiffness
, and
fever
.
[2]
[1]
Hemorrhagic stroke may occur on the background of alterations to the blood vessels in the brain, such as cerebral
arteriolosclerosis
,
cerebral amyloid angiopathy
,
cerebral arteriovenous malformation
,
brain trauma
,
brain tumors
and an
intracranial aneurysm
, which can cause intraparenchymal or subarachnoid hemorrhage.
[1]
The biggest risk factors for spontaneous bleeding are
high blood pressure
and
amyloidosis
.
[2]
Other risk factors include
alcoholism
,
low cholesterol
,
blood thinners
, and
cocaine
use.
[2]
Diagnosis is typically by
CT scan
.
[1]
Treatment should typically be carried out in an
intensive care unit
due to strict blood pressure goals and frequent use of both pressors and antihypertensive agents.
[1]
[5]
Anticoagulation
should be reversed if possible and
blood sugar
kept in the normal range.
[1]
A procedure to place an
external ventricular drain
may be used to treat
hydrocephalus
or increased
intracranial pressure
, however, the use of
corticosteroids
is frequently avoided.
[1]
Sometimes surgery to directly remove the blood can be therapeutic.
[1]
Cerebral bleeding affects about 2.5 per 10,000 people each year.
[2]
It occurs more often in males and older people.
[2]
About 44% of those affected die within a month.
[2]
A good outcome occurs in about 20% of those affected.
[2]
Intracerebral hemorrhage, a type of hemorrhagic stroke, was first distinguished from ischemic strokes due to insufficient blood flow, so called "leaks and plugs", in 1823.
[6]
Epidemiology
[
edit
]
The incidence of intracerebral hemorrhage is estimated at 24.6 cases per 100,000 person years with the incidence rate being similar in men and women.
[7]
[8]
The incidence is much higher in the elderly, especially those who are 85 or older, who are 9.6 times more likely to have an intracerebral hemorrhage as compared to those of middle age.
[8]
It accounts for 20% of all cases of
cerebrovascular disease
in the United States, behind
cerebral thrombosis
(40%) and
cerebral embolism
(30%).
[9]
Types
[
edit
]
Intraparenchymal hemorrhage
[
edit
]
Intraparenchymal hemorrhage
(IPH) is one form of
intracerebral bleeding
in which there is bleeding within brain
parenchyma
.
[10]
Intraparenchymal hemorrhage accounts for approximately 8-13% of all
strokes
and results from a wide spectrum of disorders. It is more likely to result in
death
or major
disability
than
ischemic stroke
or
subarachnoid hemorrhage
, and therefore constitutes an immediate
medical emergency
. Intracerebral hemorrhages and accompanying
edema
may disrupt or compress adjacent
brain tissue
, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of
intracranial pressure
(ICP) and potentially fatal
herniation syndromes
.
Intraventricular hemorrhage
[
edit
]
Intraventricular hemorrhage
(IVH), also known asintraventricular bleeding, is a
bleeding
into the brain's
ventricular system
, where the
cerebrospinal fluid
is produced and circulates through towards the
subarachnoid space
. It can result from
physical trauma
or from
hemorrhagic stroke
.
30% of intraventricular hemorrhage (IVH) are primary, confined to the ventricular system and typically caused by intraventricular trauma, aneurysm, vascular malformations, or tumors, particularly of the choroid plexus.
[11]
However 70% of IVH are secondary in nature, resulting from an expansion of an existing intraparenchymal or subarachnoid hemorrhage.
[11]
Intraventricular hemorrhage has been found to occur in 35% of moderate to severe
traumatic brain injuries
.
[12]
Thus the hemorrhage usually does not occur without extensive associated damage, and so the outcome is rarely good.
[13]
[14]
Signs and symptoms
[
edit
]
People with intracerebral bleeding have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed.
[15]
These localizing signs and symptoms can include
hemiplegia
(or weakness localized to one side of the body) and paresthesia (loss of sensation) including hemisensory loss (if localized to one side of the body).
[7]
These symptoms are usually rapid in onset, sometimes occurring in minutes, but not as rapid as the symptom onset in
ischemic stroke
.
[7]
While the duration of onset not be as rapid, it is important that patients go to the emergency department as soon as they notice any symptoms as early detection and management of stroke may lead to better outcomes post-stroke than delayed identification.
[16]
A mnemonic to remember the warning signs of stroke is
FAST
(facial droop, arm weakness, speech difficulty, and time to call emergency services),
[17]
as advocated by the
Department of Health (United Kingdom)
and the
Stroke Association
, the
American Stroke Association
, the
National Stroke Association
(US), the
Los Angeles Prehospital Stroke Screen (LAPSS)
[18]
and the
Cincinnati Prehospital Stroke Scale
(CPSS).
[19]
Use of these scales is recommended by professional guidelines.
[20]
FAST is less reliable in the recognition of posterior circulation stroke.
[21]
Other symptoms include those that indicate a rise in
intracranial pressure
caused by a large mass (due to hematoma expansion) putting pressure on the brain.
[15]
These symptoms include
headaches
, nausea, vomiting, a depressed level of consciousness, stupor and death.
[7]
Continued elevation in the intracranial pressure and the accompanying mass effect may eventually cause
brain herniation
(when different parts of the brain are displaced or shifted to new areas in relation to the skull and surrounding
dura mater
supporting structures). Brain herniation is associated with
hyperventilation
,
extensor rigidity
, pupillary asymmetry,
pyramidal signs
,
coma
and death.
[10]
Hemorrhage into the
basal ganglia
or
thalamus
causes contralateral hemiplegia due to damage to the
internal capsule
.
[7]
Other possible symptoms include
gaze palsies
or hemisensory loss.
[7]
Intracerebral hemorrhage into the
cerebellum
may cause
ataxia
,
vertigo
, incoordination of limbs and vomiting.
[7]
Some cases of cerebellar hemorrhage lead to blockage of the
fourth ventricle
with subsequent impairment of drainage of
cerebrospinal fluid
from the brain.
[7]
The ensuing
hydrocephalus
, or fluid buildup in the
ventricles
of the brain leads to a decreased level of consciousness,
total loss of consciousness
,
coma
, and
persistent vegetative state
.
[7]
Brainstem hemorrhage most commonly occurs in the
pons
and is associated with
shortness of breath
,
cranial nerve palsies
, pinpoint (but reactive) pupils, gaze palsies, facial weakness,
coma
, and
persistent vegetative state
(if there is damage to the
reticular activating system
).
[7]
Causes
[
edit
]
Intracerebral bleeds are the second most common cause of
stroke
, accounting for 10% of hospital admissions for stroke.
[23]
High blood pressure
raises the risks of spontaneous intracerebral hemorrhage by two to six times.
[22]
More common in adults than in children, intraparenchymal bleeds are usually due to
penetrating head trauma
, but can also be due to depressed
skull fractures
. Acceleration-deceleration trauma,
[24]
[25]
[26]
rupture of an
aneurysm
or
arteriovenous malformation
(AVM), and bleeding within a
tumor
are additional causes.
Amyloid angiopathy
is not an uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to
cerebral venous sinus thrombosis
.
[
citation needed
]
Risk factors for ICH include:
[11]
Hypertension is the strongest risk factor associated with intracerebral hemorrhage and long term control of elevated blood pressure has been shown to reduce the incidence of hemorrhage.
[7]
Cerebral amyloid angiopathy
, a disease characterized by deposition of
amyloid beta
peptides in the walls of the small blood vessels of the brain, leading to weakened blood vessel walls and an increased risk of bleeding; is also an important risk factor for the development of intracerebral hemorrhage. Other risk factors include advancing age (usually with a concomitant increase of cerebral amyloid angiopathy risk in the elderly), use of
anticoagulants
or
antiplatelet medications
, the presence of cerebral microbleeds,
chronic kidney disease
, and low
low density lipoprotein
(LDL) levels (usually below 70).
[27]
[28]
The direct oral anticoagulants (DOACs) such as the
factor Xa inhibitors
or
direct thrombin inhibitors
are thought to have a lower risk of intracerebral hemorrhage as compared to the
vitamin K antagonists
such as
warfarin
.
[7]
Cigarette smoking
may be a risk factor but the association is weak.
[29]
Traumautic intracerebral hematomas are divided into acute and delayed. Acute intracerebral hematomas occur at the time of the injury while delayed intracerebral hematomas have been reported from as early as 6 hours post injury to as long as several weeks.
[
citation needed
]
Diagnosis
[
edit
]
Both
computed tomography angiography
(CTA) and
magnetic resonance angiography
(MRA) have been proved to be effective in diagnosing intracranial vascular malformations after ICH.
[12]
So frequently, a CT angiogram will be performed in order to exclude a secondary cause of hemorrhage
[30]
or to detect a "spot sign".
Intraparenchymal hemorrhage
can be recognized on
CT scans
because blood appears brighter than other tissue and is separated from the inner table of the skull by brain tissue. The tissue surrounding a bleed is often less dense than the rest of the brain because of
edema
, and therefore shows up darker on the CT scan.
[30]
The oedema surrounding the haemorrhage would rapidly increase in size in the first 48 hours, and reached its maximum extent at day 14. The bigger the size of the haematoma, the larger its surrounding oedema.
[31]
Brain oedema formation is due to the breakdown of red blood cells, where haemoglobin and other contents of red blood cells are released. The release of these red blood cells contents causes toxic effect on the brain and causes brain oedema. Besides, the breaking down of blood-brain barrier also contributes to the odema formation.
[13]
Apart from CT scans, haematoma progression of intracerebral haemorrhage can be monitored using transcranial ultrasound. Ultrasound probe can be placed at the temporal lobe to estimate the volume of haematoma within the brain, thus identifying those with active bleeding for further intervention to stop the bleeding. Using ultrasound can also reduces radiation risk to the subject from CT scans.
[14]
Location
[
edit
]
When due to
high blood pressure
, intracerebral hemorrhages typically occur in the
putamen
(50%) or
thalamus
(15%), cerebrum (10?20%), cerebellum (10?13%), pons (7?15%), or elsewhere in the brainstem (1?6%).
[32]
[33]
Treatment
[
edit
]
Treatment depends substantially on the type of ICH. Rapid
CT scan
and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.
Medications
[
edit
]
Rapid lowering of the blood pressure using
antihypertensive therapy
for those with
hypertensive emergency
can have higher functional recovery at 90 days post intracerebral haemorrhage, when compared to those who undergone other treatments such as mannitol administration, reversal of anticoagulation (those previously on anticoagulant treatment for other conditions), surgery to evacuate the haematoma, and standard rehabilitation care in hospital, while showing similar rate of death at 12%.
[35]
Early lowering of the blood pressure can reduce the volume of the haematoma, but may not have any effect against the oedema surrounding the haematoma.
[36]
Reducing the blood pressure rapidly does not cause
brain ischemia
in those who have intracerebral haemorrhage.
[37]
The
American Heart Association
and
American Stroke Association
guidelines in 2015 recommended decreasing the blood pressure to a SBP of 140 mmHg.
[1]
However, later reviews found unclear difference between intensive and less intensive blood pressure control.
[38]
[39]
Giving
Factor VIIa
within 4 hours limits the bleeding and formation of a
hematoma
. However, it also increases the risk of
thromboembolism
.
[34]
It thus overall does not result in better outcomes in those without hemophilia.
[40]
Frozen plasma
,
vitamin K
,
protamine
, or
platelet transfusions
may be given in case of a
coagulopathy
.
[34]
Platelets however appear to worsen outcomes in those with spontaneous intracerebral bleeding on antiplatelet medication.
[41]
The specific reversal agents
idarucizumab
and
andexanet alfa
may be used to stop continued intracerebral hemorrhage in people taking directly oral acting anticoagulants (such as factor Xa inhibitors or direct thrombin inhibitors).
[7]
However, if these specialized medications are not available,
prothrombin complex concentrate
may also be used.
[7]
Only 7% of those with ICH are presented with clinical features of seizures while up to 25% of those have subclinical seizures. Seizures are not associated with an increased risk of death or disability. Meanwhile, anticonvulsant administration can increase the risk of death. Therefore, anticonvulsants are only reserved for those that have shown obvious clinical features of seizures or seizure activity on
electroencephalography
(EEG).
[42]
H2 antagonists or proton pump inhibitors are commonly given to try to prevent
stress ulcers
, a condition linked with ICH.
[34]
Corticosteroids
were thought to reduce swelling. However, in large controlled studies, corticosteroids have been found to increase mortality rates and are no longer recommended.
[43]
[44]
Surgery
[
edit
]
Surgery is required if the
hematoma
is greater than 3 cm (1 in), if there is a structural
vascular
lesion
or
lobar
hemorrhage
in a young patient.
[34]
A
catheter
may be passed into the brain
vasculature
to close off or dilate
blood vessels
, avoiding invasive surgical procedures.
[45]
Aspiration by
stereotactic surgery
or
endoscopic
drainage may be used in
basal ganglia
hemorrhages, although successful reports are limited.
[34]
A
craniectomy
holds promise of reduced mortality, but the effects of long?term neurological outcome remain controversial.
[46]
Prognosis
[
edit
]
About 8 to 33% of those with intracranial haemorrhage have neurological deterioration within the first 24 hours of hospital admission, where a large proportion of them happens within 6 to 12 hours. Rate of haematoma expansion, perihaematoma odema volume and the presence of fever can affect the chances of getting neurological complications.
[47]
The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the
brain stem
.
[48]
Intraparenchymal bleeds within the
medulla oblongata
are almost always fatal, because they cause damage to cranial nerve X, the
vagus nerve
, which plays an important role in
blood circulation
and breathing.
[24]
This kind of hemorrhage can also occur in the
cortex
or subcortical areas, usually in the
frontal
or
temporal lobes
when due to head injury, and sometimes in the
cerebellum
.
[24]
[49]
Larger volumes of hematoma at hospital admission as well as greater expansion of the hematoma on subsequent evaluation (usually occurring within 6 hours of symptom onset) are associated with a worse prognosis.
[7]
[50]
Perihematomal edema, or secondary edema surrounding the hematoma, is associated with secondary brain injury, worsening neurological function and is associated with poor outcomes.
[7]
Intraventricular hemorrhage, or bleeding into the ventricles of the brain, which may occur in 30?50% of patients, is also associated with long-term disability and a poor prognosis.
[7]
Brain herniation is associated with poor prognoses.
[7]
For spontaneous intracerebral hemorrhage seen on CT scan, the death rate (
mortality
) is 34?50% by 30 days after the injury,
[22]
and half of the deaths occur in the first 2 days.
[51]
Even though the majority of deaths occur in the first few days after ICH, survivors have a long-term excess mortality rate of 27% compared to the general population.
[52]
Of those who survive an intracerebral hemorrhage, 12?39% are independent with regard to self-care; others are disabled to varying degrees and require supportive care.
[8]
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[
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