Intracerebral Hemorrhage (Hemorrhagic Stroke)

What happens in an intracerebral hemorrhage

A small artery inside the brain ruptures and blood spills into the surrounding tissue, forming a hematoma. The blood destroys brain cells directly, raises pressure inside the skull and triggers swelling and inflammation. In about a third of people, the hematoma keeps growing in the first few hours, which is why speed matters. Blood can also leak into the fluid-filled spaces of the brain (intraventricular hemorrhage), causing hydrocephalus.

ICH differs from subarachnoid hemorrhage, which is bleeding into the space around the brain, usually from a burst aneurysm, and from ischemic stroke, caused by a blocked artery. Stroke symptoms alone cannot tell them apart. Only a scan can.

Symptoms

Symptoms usually start suddenly and may worsen over minutes to hours:

• weakness or numbness of the face, arm or leg, usually on one side
• slurred speech, or difficulty speaking or understanding
• loss of vision or double vision
• loss of balance and coordination
• severe headache, more common than in ischemic stroke
• nausea and vomiting
• drowsiness, confusion or loss of consciousness
• seizures

The BE FAST check helps: Balance, Eyes, Face drooping, Arm weakness, Speech difficulty, Time to call 911.

Causes and risk factors

Other risk factors include older age, heavy alcohol use, smoking, low cholesterol in some studies, and kidney disease. Hypertension is by far the most important modifiable risk factor.

Diagnosis

• Non-contrast CT of the head: detects fresh blood within minutes and is done immediately on arrival.
• CT angiography: looks for an underlying malformation or aneurysm, and a "spot sign" of active bleeding that predicts growth.
• MRI: identifies amyloid angiopathy (small old bleeds called microbleeds), tumors and cavernous malformations.
• Blood tests: blood count, clotting tests and kidney function.
• Catheter angiography in younger people or when a vascular cause is suspected.

Treatment

Emergency care

• Lower blood pressure promptly to a target systolic pressure around 140 mm Hg in many patients, following AHA/ASA guidance, to reduce hematoma growth.
• Reverse blood thinners: vitamin K and prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, and andexanet alfa or prothrombin complex concentrate for factor Xa inhibitors.
• Protect the airway and breathing, often in a neuro-intensive care unit.
• Treat seizures if they occur.
• Manage brain pressure: raising the head, medicines, and an external ventricular drain for hydrocephalus.
• Prevent complications: blood clot prevention in the legs with compression devices, swallow assessment before eating, blood sugar and temperature control.

Surgery

Surgery is considered for:

• cerebellar hemorrhages that are large, compress the brainstem or cause hydrocephalus
• lobar hemorrhages close to the surface in selected patients
• minimally invasive evacuation for some supratentorial bleeds, an area of active research with growing evidence
• treating an underlying arteriovenous malformation or aneurysm

Rehabilitation

Recovery relies on early physical, occupational and speech therapy. Much of the recovery happens in the first 3 to 6 months, but improvement can continue for a year or more.

Outlook

ICH is the most deadly type of stroke. Roughly 40% of people die within a month, according to large studies, and many survivors have lasting disability. Outcomes depend on bleed size and location, age, level of consciousness on arrival, intraventricular blood and blood thinner use. Survivors with smaller bleeds can make good recoveries.

Preventing another bleed

• Control blood pressure: usually to under 130/80 mm Hg, the single most effective measure.
• Review blood thinners: whether to restart anticoagulation depends on the reason it was needed and the bleeding risk. Left atrial appendage closure is an option for some people with atrial fibrillation.
• Avoid heavy alcohol use and stimulant drugs.
• Stop smoking.
• Treat any underlying malformation.

Frequently asked questions

What is an intracerebral hemorrhage?

It is bleeding directly into the brain tissue from a ruptured blood vessel, a type of hemorrhagic stroke. The blood damages brain cells and raises pressure inside the skull. It causes sudden stroke symptoms and is a medical emergency.

What are the warning signs of a brain bleed?

Warning signs include sudden weakness or numbness on one side, facial droop, slurred speech, vision loss, loss of balance, a sudden severe headache, vomiting, confusion and drowsiness. Call 911 immediately if these appear.

What causes bleeding in the brain?

The most common cause is long-standing high blood pressure, which weakens small arteries deep in the brain. Others include cerebral amyloid angiopathy in older adults, blood thinners, abnormal blood vessels, brain tumors, drug use such as cocaine, and head injury.

Can you recover from an intracerebral hemorrhage?

Many people recover partially or fully, especially after smaller bleeds and with early rehabilitation. Recovery is fastest in the first 3 to 6 months but can continue for a year or more. Larger bleeds often cause lasting disability, and ICH has a high death rate.

How is a hemorrhagic stroke treated?

Treatment focuses on lowering blood pressure, reversing any blood thinners, supporting breathing, controlling brain pressure and preventing complications in intensive care. Some patients need surgery to remove the clot or drain fluid. Rehabilitation begins as soon as possible.