Intracerebral hemorrhage

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Intracerebral hemorrhage
Other names: Cerebral haemorrhage, cerebral hemorrhage, intra-axial hemorrhage, cerebral hematoma, cerebral bleed, brain bleed
CT scan of a spontaneous intracerebral bleed, leaking into the lateral ventricles
SymptomsHeadache, one-sided weakness, vomiting, seizures, decreased level of consciousness, neck stiffness, fever[1][2]
CausesBrain trauma, aneurysms, arteriovenous malformations, brain tumors[1]
Risk factorsHigh blood pressure, amyloidosis, alcoholism, low cholesterol, blood thinners, cocaine use[2]
Diagnostic methodCT scan[1]
Differential diagnosisIschemic stroke[1]
TreatmentBlood pressure control, surgery, ventricular drain [1]
Prognosis20% good outcome[2]
Frequency2.5 per 10,000 people a year[2]
Deaths44% die within one month[2]

Intracerebral hemorrhage (ICH), also known as cerebral bleed, is a type of intracranial bleed that occurs within the brain tissue or ventricles.[3] Symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness.[2] Often symptoms get worse over time.[1] Fever is also common.[1] In many cases bleeding is present in both the brain tissue and the ventricles.[1]

Causes include brain trauma, aneurysms, arteriovenous malformations, and brain tumors.[1] The largest 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] It is a type of hemorrhagic stroke.[4] Other conditions that may present similarly include ischemic stroke.[1]

Treatment should typically be carried out in an intensive care unit.[1] Guidelines recommended decreasing the blood pressure to a systolic of 130 to 140 mmHg.[5][6] Blood thinners should be reversed if possible and blood sugar kept in the normal range.[1] Surgery to place a ventricular drain may be used to treat hydrocephalus but corticosteroids should not be used.[1] Surgery to remove the blood is useful in certain cases.[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 was first distinguished from strokes due to insufficient blood flow, so called "leaks and plugs", in 1823.[7]

Signs and symptoms

People with intracerebral bleeding have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed.[8] Other symptoms include those that indicate a rise in intracranial pressure caused by a large mass putting pressure on the brain.[8] Intracerebral bleeds are often misdiagnosed as subarachnoid hemorrhages due to the similarity in symptoms and signs. A severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage. Collapsing is another symptom. Some people may experience continuous bleeding from the ear. Some patients may also go into a coma before the bleed is noticed.


Intracerebral bleeds are the second most common cause of stroke, accounting for 10% of hospital admissions for stroke.[9] High blood pressure raises the risks of spontaneous intracerebral hemorrhage by two to six times.[10] 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,[11][12][13] rupture of an aneurysm or arteriovenous malformation (AVM), and bleeding within a tumor are additional causes. Amyloid angiopathy is a not uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis.

Risk factors for ICH include:[14]

Cigarette smoking may be a risk factor but the association is weak.[15]

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.


Both computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been proved to be effective in diagnosing intracranial vascular malformations after ICH.[16] So frequently, a CT angiogram will be performed in order to exclude a secondary cause of hemorrhage[17] 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.[17]


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%).[18][19]


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.



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.[20]


The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the brain stem.[31] 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.[11] 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.[11][32]

For spontaneous ICH seen on CT scan, the death rate (mortality) is 34–50% by 30 days after the insult,[10] and half of the deaths occur in the first 2 days.[33] Even though the majority of deaths occurs in the first days after ICH, survivors have a long term excess mortality of 27% compared to the general population.[34]


It accounts for 20% of all cases of cerebrovascular disease in the United States, behind cerebral thrombosis (40%) and cerebral embolism (30%).[35]


Intracerebral hemorrhage was first distinguished from strokes due to insufficient blood flow, so called "leaks and plugs", in 1823.[7]


The inflammatory response triggered by stroke has been viewed as harmful in the early stage, focusing on blood-borne leukocytes, neutrophils and macrophages, and resident microglia and astrocytes.[36][37] A human postmortem study shows that inflammation occurs early and persists for several days after ICH.[38] Modulating microglial activation and polarization might mitigate intracerebral hemorrhage-induced brain injury and improve brain repair.[39] A new area of interest is the role of mast cells in ICH.[40][37]


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Further reading

  • Hemphill JC, 3rd; Greenberg, SM; Anderson, CS; Becker, K; Bendok, BR; Cushman, M; Fung, GL; Goldstein, JN; Macdonald, RL; Mitchell, PH; Scott, PA; Selim, MH; Woo, D (28 May 2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke: A Journal of Cerebral Circulation. 46 (7): 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637.

External links