Hemorrhages in the brain are more serious than strokes and can be life-threatening. Early neurosurgical consultation and proper evaluation, imaging, and monitoring protocols are critical.
Hemorrhages in the brain can cause loss of consciousness, vomiting and headache. They are often accompanied by high blood pressure. Most people with ICH recover, but they may have long-term disabilities and need around-the-clock care.
Hemorrhage in the brain is often caused by a blow to the head or by an injury related to a car accident, falling, or playing sports. It can also be the result of a blood-clotting disease or some diseases that affect the blood vessels, such as aspirin use or having an arteriovenous malformation. It is the second most common cause of stroke, and can be fatal.
The sudden leakage of blood can damage the tissue in the brain, increase pressure inside the skull (intracranial pressure) to a dangerous level, or both. The extra pressure from the leaking blood can press on nerve cells and disrupt or compress them, leading to problems with thinking, feeling, or moving. The bleeding can also irritate or inflame the brain, which can lead to further damage and swelling.
A hematoma may be formed when a blood vessel bursts between the brain and the outermost layer of its protective covering, called the dura mater. This type of bleed is called subdural hemorrhage. Symptoms usually begin immediately when this happens. It is more dangerous than an intraparenchymal hemorrhage because it can lead to a herniation of the fluid and brain tissues.
An intraparenchymal hemorrhage occurs when the bleed is in the brain itself. It is less common than a subarachnoid hemorrhage but can be just as serious. There are 4 broad types of hemorrhage affecting the brain, with the first two being referred to as extra-axial hemorrhages, and the latter 2 being referred to as intra-axial hemorrhage. Each has its own etiology, clinical findings, prognosis, and outcome.
A bleed may occur when an aneurysm in the blood vessels that carry blood to and from the brain ruptures. A hemorrhage may also be the result of a brain tumor, a bleeding disorder, or an overdose of certain anticoagulants. Other risk factors include being born with poor connections between arteries and veins, having an abnormal bulge in the artery walls of the brain (cerebral aneurysm), an abnormal connection between arteries and veins within the skull (arteriovenous malformation), injuries, blood vessel inflammation or infection, and bleeding disorders or taking too much aspirin.
When a person experiences a hemorrhage in the brain, they can lose consciousness within seconds or a few minutes. This can cause them to become confused and less able to think clearly or remember things. They may also have a headache or nausea. If the bleed is small, it may not affect consciousness and symptoms may be mild or absent. As the clot expands, however, symptoms will get worse.
If the clot extends into the ventricles, this can lead to a condition called hydrocephalus. This is when cerebrospinal fluid, which normally surrounds the brain and spinal cord, cannot leave the brain and causes pressure on the brain. The symptoms of hydrocephalus are a headache, confusion, vomiting, and a decreased level of consciousness (measured on the Glasgow Coma Scale).
Approximately half of people who suffer a large hemorrhage die within a few days. Others are more likely to have problems such as a reduced level of consciousness, loss of muscle control, or memory problems. These problems may improve gradually as the brain absorbs blood and relieves pressure.
Hemorrhages caused by a ruptured aneurysm are more dangerous than other types of intracerebral hemorrhage because the risk of death is much higher. However, even when the hemorrhage is not due to an aneurysm, it can be fatal if it occurs in the area of the brain where the person has poor blood flow, such as the thalamus.
In most cases, a brain hemorrhage is accompanied by high blood pressure, which reduces the amount of oxygen delivered to the brain cells. This can damage the brain cells and cause a stroke. The risk of this occurring is increased if the blood clot in the brain is not removed promptly and the blood pressure is allowed to return to a normal level.
Doctors will assess a patient’s symptoms, history, current and past health problems, medications, and family history. They will then do diagnostic tests to check for the source of the bleeding. These tests include a CT scan, an MRI, and blood tests. The test results help doctors decide on the best treatment for a person with a brain hemorrhage.
Diagnoses of intracerebral hemorrhage usually occur in the emergency room because of the symptoms’ sudden onset. They are often confused with ischemic strokes, which cause clots or blocked blood vessels (see Stroke). It is important to distinguish these two types of stroke because treatment differs and hemorrhagic strokes must be stopped immediately as they can rapidly worsen and damage brain tissue.
The initial symptoms are often quite dramatic and include sudden onset of headache, drooping eyelids (ptosis), dizziness, or loss of balance, weakness in one side of the body or difficulty moving the affected arm or leg. People may also experience a change in personality or mood and numbness in the affected area of the body.
To confirm the diagnosis, doctors will order several tests to determine the location and extent of the bleed in your brain. These may include computed tomography (CT) or magnetic resonance imaging (MRI). CT and MRI can show the presence of a hematoma, its location in the brain, and whether any of your brain has been displaced by the bleed.
If the doctor suspects a problem with your blood vessels that may be contributing to the hemorrhage, they can perform an angiogram, in which they inject dye into your bloodstream to make your arteries visible on X-ray images. Angiograms can help identify leaking aneurysms and arteriovenous malformations.
A sample of cerebrospinal fluid can also be examined to detect any signs of bleeding in the fluid that surrounds your brain. In some cases, a lumbar puncture, or spinal tap, will be done to obtain this fluid sample.
In most cases, doctors will use a combination of medical and surgical treatment to prevent rebleeding from occurring and to reduce the amount of blood in the brain. Surgery may be necessary to drain a hemorrhage, repair the source of the bleeding (such as an aneurysm or arteriovenous malformation), or both. At UPMC, doctors specialize in neuroendoport surgery, a minimally invasive technique for treating hemorrhages within the white matter of your brain. This procedure allows them to directly access and drain the hemorrhage without needing to open your skull.
A brain hemorrhage is a medical emergency. If left untreated, it can cause a stroke and result in coma or death. The risk of death from intracerebral hemorrhage increases with age, and is higher in men than women. Treatment is focused on managing problems that may contribute to bleeding (such as high blood pressure) and, if necessary, surgically draining or removing the accumulated blood.
A traumatic brain injury, such as a car accident, is the most common cause of intracerebral hemorrhage in people under 60. It can also occur due to chronic high blood pressure, or as a side effect of some medications and substances, such as cocaine or illegal drugs.
Non-traumatic intraparenchymal hemorrhage can also be caused by aneurysms, arteriovenous malformations, or head trauma. The symptoms are usually much less severe than those from a stroke, but they include a sudden and severe headache (often described as “the worst headache of my life”), nausea or vomiting, a quick onset of numbness or weakness, blurred vision, difficulty or inability to balance, or loss of consciousness.
The diagnosis of intracerebral hemorrhage is made based on a complete history and physical examination, including checking the patient’s blood pressure. A CT scan or magnetic resonance imaging (MRI) scan of the head and neck is used to identify the area of the brain affected by the bleed. In addition, an MRI or CT scan of the spinal cord may be needed to look for signs of a condition called hydrocephalus, which occurs when cerebrospinal fluid builds up in the space surrounding the brain and puts pressure on it.
In most cases, the blood clot in an intracerebral hemorrhage will disperse on its own as it is slowly absorbed by the brain tissue. Nevertheless, doctors recommend taking medication to prevent blood clots from forming in the first place. They also advise patients to quit smoking, reduce alcohol intake, and treat underlying conditions such as high blood pressure and diabetes. They may also suggest wearing a seat belt when driving or riding in a car, and limiting the use of medications such as anticoagulants or aspirin.
Hemorrhage in the brain, called intracerebral hemorrhage (ICH), is caused by rupture of tiny arteries within the brain. This causes bleeding that builds up in a mass that increases pressure on the brain.
Conditions that increase the risk of ICH include high blood pressure, cigarette smoking and an unhealthy diet. You can prevent hemorrhage by following a healthy lifestyle, managing diseases that cause damage to blood vessels and taking medication as prescribed.
A pounding headache is the most common symptom of intracerebral hemorrhage. The pain is generally felt on one side of the head and may get worse over time. It can be accompanied by nausea or vomiting and weakness on that side of the body. Symptoms are often severe and appear suddenly, although the buildup of blood can take weeks or longer to develop.
An intracerebral hemorrhage, or brain bleed, is a life-threatening emergency. It occurs when blood bursts into brain tissue and interferes with the oxygen supply to the rest of the body. A bleed in the brain may be caused by an injury or by the rupturing of a blood vessel, but it is most commonly due to a clot in an artery that supplies the affected area. The condition is less common than the more serious type of stroke, called an ischemic attack, which occurs when a clot blocks blood flow to the brain.
Symptoms of a brain bleed can include sudden weakness or difficulty moving on one side of the body, blurred vision, and trouble with speech or understanding what others are saying. The patient may also feel dizzy or lightheaded, and the bleed may lead to bleeding in other areas of the head.
Hemorrhage associated with migraine is thought to occur because migraine medications cause vasoconstriction that irritates the walls of blood vessels, leading them to break open and bleed. The bleed is often aggravated by stress or other factors, such as smoking, alcohol use, or taking medication, such as anticoagulants used for heart disease.
Hemorrhage in the brain can occur at any age, but it is more common in older adults. It is more likely to happen in people who have a history of blood-clot diseases, such as atherosclerosis or deep vein thrombosis. Other conditions that can cause a brain bleed are blood vessel abnormalities present at birth (cerebral aneurysms), or a defect in the connection between arteries and veins, such as a cavernous malformation or arteriovenous malformation. The risk of hemorrhage is higher if you have a family history of the disease, are pregnant or breastfeeding, have uncontrolled high blood pressure, smoke, or have diabetes or heart disease.
A brain bleed or hemorrhage can cause a lot of blood to build up inside the tissue in your head. This slow accumulation of blood can be dangerous if it puts pressure on your brain, which could lead to a stroke. This type of stroke is called a hemorrhagic stroke, and the most common warning sign is a severe headache. Symptoms of this condition vary depending on which part of your brain is affected and may get worse over time. This bleed can also cause your vision to become blurry, and you may have trouble walking or speaking.
A hemorrhage in your brain can also lead to vomiting. The nausea is caused by the blood in your head, which raises your intracranial pressure and can affect your breathing. It can also be a sign of an underlying condition that needs to be treated, such as high blood pressure or diabetes.
There are three types of brain bleeds: a subarachnoid hemorrhage, which happens under the arachnoid layer on the meninges, or in the fluid space surrounding the brain and spine; an intraparenchymal hemorrhage, which is in the actual brain tissue; and an intraventricular hemorrhage, which occurs in the ventricles (fluid chambers) of the brain. Hemorrhages are most often due to high blood pressure, but they can also be caused by a brain tumor, a clot in a carotid artery, a hemangioma, moyamoya disease or other vascular malformations.
If you experience the symptoms of a brain bleed, your doctor will check your condition with an X-ray CT scan or magnetic resonance imaging (MRI) test to identify the location and extent of the bleeding. You may also need an electroencephalogram to measure the activity of your brain’s nerve cells, or a spinal tap test to check cerebrospinal fluid pressure.
You can help to prevent hemorrhagic stroke by controlling your blood pressure, losing excess weight, eating a healthy diet and exercising regularly, not smoking, and taking medication as prescribed. It is especially important to stick with your treatment plan if you are on an anticoagulant drug like warfarin.
Seizures are associated with intracerebral hemorrhage, although they don’t occur in every case. They’re more common in people who have a hemorrhagic stroke (bleeding inside the brain) than in those who have an ischemic attack (blood blockage). People who experience hemorrhage tend to be younger than those who have an ischemic attack, and they’re more likely to be male.
ICH is caused by a ruptured blood vessel, unlike an ischemic attack, which results from blocked blood flow. People who have a hemorrhage are often at a higher risk of having another stroke, and they’re more likely to die. It’s therefore important to recognize the symptoms of ICH and seek medical attention immediately.
Hemorrhage within the skull can affect the brain’s structure, and it can also put pressure on the nerves in the head and neck. This may cause headaches, nausea, vomiting, and a decrease in the patient’s conscious level, measured on the Glasgow Coma Scale.
In a study of 408 people who experienced intracerebral hemorrhage, researchers found that if someone had seizures in the first week after their stroke, they had a worse functional outcome than those who did not have seizures. However, there are still insufficient data to determine whether anti-seizure medications might improve outcomes for these patients.
Intracerebral hemorrhage can occur in the brain itself, or it can happen in a layer of watery fluid called the subarachnoid space that surrounds and cushions the brain and spinal cord. Hemorrhage in this layer is called a subarachnoid hemorrhage, and it’s more common than intracerebral hemorrhage.
A CT scan, an MRI, and a neurological exam may be done to check for internal bleeding or blood accumulation in the brain. Depending on the location and cause of the bleeding, doctors may also perform a lumbar puncture, which involves injecting a sample of cerebrospinal fluid into the spine. However, this procedure is not usually recommended because it can be dangerous. The treatment for a hemorrhage in the brain varies by the location, cause, and extent of the bleeding. Medications to control pain, prevent more bleeding, and alleviate swelling are commonly used. Doctors will prescribe painkillers, drugs to lower blood pressure, and, if necessary, surgery to remove the accumulated blood.
This is the second most common cause of stroke and the deadliest type, because blood pools in brain tissue, damaging cells. It’s usually caused by a weakened blood vessel, such as an aneurysm or a blood vessel abnormality, but high blood pressure can also cause it. The main warning sign is a sudden, severe headache. The bleed is sometimes small and does not affect consciousness, but it can be fatal if it’s large.
If you lose consciousness, call 911 immediately and describe your symptoms to the emergency medical team. They will perform a thorough physical examination, including a neurological evaluation. They will ask you about your medical history, especially if you have diabetes or epilepsy and whether you’re taking any medications, such as aspirin. They may order a blood test, which will reveal your hemoglobin levels and tell them if you have anemia. A CBC will also show whether you have an infection, such as meningitis or pneumonia.
Symptoms of intracerebral hemorrhage can vary depending on the location of the bleeding and subsequent edema. They can include sudden onset of focal neurological deficit that progresses over minutes to hours, a diminished level of consciousness (measured with the Glasgow Coma Scale), nausea or vomiting, delirium, slurred speech, ophthalmoplegia, tetraplegia, conjugate eye deviation or ophthalmoplegia, seizures (convulsive and non-convulsive) and a raised diastolic blood pressure. If the clot extends to the ventricles, a condition called hydrocephalus develops.
Other types of stroke can convert to a hemorrhagic stroke, such as one that starts without bleeding but is caused by an embolic stroke that results from a clot that travels through the arteries that supply the brain and reaches the brain (causes of embolic stroke). Hemorrhagic conversion can also happen if a stroke begins with bleeding in another part of the body and then breaks open, such as a thrombotic stroke that develops from a blocked blood vessel in the neck or legs, or a hematologic stroke from a bleeding disorder, like sickle cell disease or von Willebrand disease.
Syncope is a brief loss of consciousness that’s usually followed by a quick recovery. It can happen during exercise or after urinating or defecating (situational syncope), or from conditions that interfere with the blood’s flow, such as low blood pressure in the brain (hypotension), problems with the heart valves (aortic stenosis or pulmonic stenosis) and arteriovenous malformations.
A brain hemorrhage occurs when blood pools in the tissue of your brain. It is the second most common cause of stroke and the deadliest. Most often, it happens because of long-term high blood pressure (hypertension).
The treatment goal is to stabilize the person quickly and relieve the pressure on the brain. This includes lowering the blood pressure and correcting any coagulopathy with fresh frozen plasma, platelet transfusions and protamine.
A large hematoma puts pressure on the brain and can cause symptoms like headache, confusion, vomiting, loss of consciousness, and seizures. Doctors can tell if a person is experiencing a hemorrhage by examining them and taking blood tests. They can also order an MRI or CT scan to get detailed images of the brain and blood vessels to better identify the cause of the hemorrhage. Blood tests can reveal blood-clotting problems, disorders of the immune system, and other conditions that could contribute to bleeding in the brain.
Treatment for intracerebral hemorrhage varies depending on the location of the hematoma and its size. In general, doctors aim to stop the bleeding, reduce swelling, and prevent blood from building up in the skull. The emergency room physician may also prescribe medications to control blood pressure, stop or prevent seizures, and ease pain and discomfort.
Medications used in the intensive care unit include acetaminophen to reduce fever and headache, anticonvulsants to reduce the risk of seizures, clot-dissolving agents to prevent blood clots, and medications to lower brain pressure. Some people with ICH develop hydrocephalus, which occurs when cerebrospinal fluid is blocked from leaving the brain. Hydrocephalus can increase the risk of coma and death.
People who survive a hemorrhage usually recover consciousness and some brain function over time, though they don’t always fully regain lost functions. Hemorrhagic strokes are less deadly than ischemic strokes because the blood that leaks out of the brain doesn’t rob the brain of its oxygen supply.
Research suggests that improving the sequence of patient care and specialized interventions can help reduce mortality and improve recovery outcomes from hemorrhagic stroke. The Mount Sinai Health System has been working with partners to understand why some people wait longer than others to receive treatment for a brain hemorrhage, and to find ways to provide more timely access to care. The team has found that many of the factors that influence how long a person waits for treatment also affect the outcome of their condition. The team is conducting further studies to identify additional factors and to roll out initiatives to ensure that all patients receive the care they need more quickly.
When a person has a seizure, the brain sends out electrical impulses that make the muscles twitch or jerk. This may cause the head to bump into something, or it may cause someone to fall. A seizure can also lead to loss of consciousness or death.
Seizures that occur in the brain are called focal seizures and can last for a few minutes. They can happen while the person is asleep or awake. They are usually caused by changes in the way nerve cells communicate. These changes may be due to certain conditions such as frontal lobe epilepsy, low blood sodium (which can happen with some medicines that make you urinate more), or low levels of oxygen in the brain.
Health care professionals use a variety of tests to diagnose this condition and determine the best treatment option. These include a CT scan, MRI, and a neurological exam. They also run blood tests to check the amount of red and white blood cells in the blood.
Surgery is often done to stop the bleeding, remove the clot, and relieve pressure on the brain. However, if the clot has been present for a long time, damage to the brain from increased pressure and the accumulation of blood toxins may be irreversible.
Medications are used to control pain, headaches, and seizures. Some of these medications can also help reduce the risk of future seizures. A doctor can also prescribe physical and occupational therapy to help people regain their strength and ability to function.
The symptoms of intracerebral hemorrhage are similar to those of a stroke. These symptoms include a severe headache described as a “thunderclap,” nausea, vomiting, syncope (passing out), photophobia (“color blindness”), nuchal rigidity, and seizures. People who have an intracerebral hemorrhage tend to be younger than those who experience the more common type of stroke known as an ischemic attack.
If you have a history of seizures, your doctor may suggest that you avoid certain foods, drinks, or activities to prevent a seizure. They may also recommend that you take an antiepileptic medication. If you think you’re about to have a seizure, look around for a safe place and try to stay calm. You can also ask your doctor about participating in a clinical trial so that researchers can learn more about how to treat seizures.
The intensive care unit (ICU) is usually the next step after a patient has had a brain hemorrhage. It is a specialised hospital area where patients receive detailed observation and medical or surgical treatment, which cannot be provided in a general ward or high dependency unit. Intensive care is generally reserved for patients who are at risk of serious coexisting illness and have a poor prognosis. This includes those who are elderly or have a terminal illness. Intensive care can be difficult and frightening, but patients are able to express their wishes for their treatment through an advance directive or other documented form.
A person who has a large hemorrhage may die within a few days, but in those who survive, consciousness returns and problems caused by the hemorrhage usually slowly improve. A complication of large hemorrhages is hydrocephalus, in which cerebrospinal fluid is blocked from leaving the brain. This increases pressure within the skull, which can be fatal.
Treatment of intracerebral hemorrhage focuses on stopping the bleeding, removing the blood clot (hemorrhage), and relieving pressure on the brain. Anticonvulsants can prevent seizures, and diuretics such as mannitol can decrease the amount of fluid in the skull, which reduces pressure on the brain. Medications are also given to control blood pressure and heart disease, prevent infection, treat shock and other illnesses, and improve nutrition and digestion.
It is important to make an effort to diagnose ICH and start therapy promptly. ICH has the worst outcome of all stroke subtypes, but with prompt diagnosis and early referral to intensive care, the chance of recovery is improved. Clear criteria should be used to identify patients at risk of a poor prognosis and ensure that these patients are admitted.
Spontaneous intracerebral hemorrhage accounts for 10% of all strokes and a significantly higher percentage of deaths due to stroke. The ideal surgical treatment for this condition has yet to be established. Numerous surgical trials have offered conflicting results. In 1995, randomization of the landmark Surgical Trial in Intracerebral Hemorrhage (STICH) commenced. STICH compared early surgery to conservative best medical therapy in 1033 patients with spontaneous supratentorial intracerebral hemorrhage. Hemorrhage size, location, and volume were similar in the two groups. The main goal of surgery was to remove the clot to prevent brain swelling and cerebral herniation.
Surgery was performed using either minimally invasive surgery or microendoscopic techniques. Minimal invasive methods use small incisions through the skull to access the clot. Often, the clot can be removed by gentle suction with irrigation. Occasionally, larger clots may need to be dislodged with a biopsy forcep. During clot removal, care is taken to avoid inadvertent injury to adjacent brain tissue and blood vessels.
After removing the clot, the surgeon may leave a catheter in place inside the hematoma. Frequent small doses of recombinant tissue plasminogen activator (r-tPA) are then given through the catheter to further dislodge and drain the clot over the course of several days.
Most people who experience an intracerebral hemorrhage stay in a hospital stroke unit or intensive care unit for monitoring and close treatment of problems that occur. They will remain on blood thinners and will receive reversal medications to help the body reabsorb any excess clotting factors that may have been caused by the bleeding.
The need for surgery depends on the size, location, and extent of the hemorrhage and patient age. Larger clots that involve the basal ganglia, pons, thalamus, or cerebellum and those that are compressing the brainstem and causing hydrocephalus require surgical intervention to prevent deterioration. The need for surgical intervention also is more likely in older people who have a history of chronic high blood pressure. If the bleed is not addressed promptly, it can lead to life-threatening complications including cerebral herniation, ventricular dilation, and brainstem compression with resulting severe hydrocephalus.
