Intracerebral Hemorrhage (Hypertensive Hemorrhage)

What Is It?

An intracerebral hemorrhage is a spontaneous hemorrhage (bleeding) into the brain. While there are several causes of hemorrhage into the brain, such as an arteriovenous malformation, head trauma, amyloid angiopathy or even a cerebral aneurysm, this page is devoted specifically to what is known as hypertensive hemorrhage, intracerebral hemorrhage due to high blood pressure.

Hypertensive hemorrhage is one of the most common causes of spontaneous bleeding into the brain. Hypertension, high blood pressure, can lead to several forms of injury to blood vessels over time. It is a significant risk factor for blood vessel disease throughout the body, including coronary artery disease, peripheral vascular disease and stroke. With high blood pressure, some of the small arteries within the brain become injured and diseased. This can lead to a spontaneous rupture of these arteries, leading to a brain hemorrhage.

This type of bleed into the brain, intracerebral hemorrhage, can be considered one form of hemorrhagic stroke because it happens suddenly, often without any warning sign other than long-standing high blood pressure. Additionally, some of the presenting symptoms can be similar to those of ischemic stroke. However, it should not be confused with ischemic stroke which is due to a blood clot blocking blood flow to a part of the brain, not bleeding into the brain.

What Types of Symptoms Are Typical?

Patients with a hypertensive brain hemorrhage typically present with the sudden onset of new neurological symptoms. The specific symptoms depend on the size of the hemorrhage and its location in the brain.

The most common site for these hemorrhages are the deep grey matter of the brain, including areas called the basal ganglia and the thalamus. They occur deep in the brain. In this type of hemorrhage common symptoms include hemiparesis or hemiplegia (weakness or paralysis of the opposite side of the body) because the fibers of the motor system (called the internal capsule) run right alongside this location in the brain. Hemorrhage in the dominant hemisphere (usually the left side in most patients) can result in aphasia (abnormalities in the comprehension or production of normal language). If the hematoma is large enough it can increase the pressure on the brain in general and lead to a deterioration in the level of consciousness including coma and death if severe enough.

Another area where hypertensive hemorrhage can occur is in the pons, part of the brain stem. Hemorrhage in this area can often lead to coma or death because of the importance of the brain stem in the normal functions that support life (alertness, breathing, etc.).

Finally, hemorrhage can occur in the cerebellum, a part of the brain important for motor coordination and gait. Symptoms associated with these hematomas can include unbalanced gait, poor coordination and instability. If large enough they can obstruct the fourth ventricle, a fluid-filled space within the brain, and lead to acute hydrocephalus.

How Is The Diagnosis Typically Made?

If a patient with high blood pressure presents with the sudden onset of new neurological symptoms, the diagnosis of intracerebral hemorrhage is generally made on an imaging study such as a CT scan or MRI scan which demonstrates a hemorrhage within the brain in one of the usual locations. Because some of the symptoms may be similar to ischemic stroke (weakness of half the body, difficulty with speech and language, etc.), this must be ruled out. Generally the CT scan is adequate to demonstrate the hemorrhage.

If the patient does not have a history of hypertension or the location of the hemorrhage is not typical, other causes of intracerebral bleeding, such as arteriovenous malformation, amyloid angiopathy or a cerebral aneurysm is usually assessed.

What Are Some Common Treatments?

Treatment varies depending on the specifics of each case and cannot be generalized to all patients. However, most patients are admitted to the intensive care unit and undergo general supportive measure and observation. Aggressive surgery to remove the hematoma has been show to not be beneficial in most patients. However, for very large hemorrhages surgery is sometimes considered. This can be performed through a large craniotomy or sometimes through a small opening with an endoscope.

In some centers a catheter is placed into the hematoma and a drug called tPA is injected to attempt to break up and drain the clotted blood.

In patients with hemorrhage into the cerebellum surgery is more frequently recommended to prevent brain stem compression and hydrocephalus. If hydrocephalus is present, a ventriculostomy catheter is sometimes placed to decreased the pressure inside the head.

The treatment and prognosis of intracerebral hemorrhage is quite variable depending on the location, size and presenting symptoms. Each case should be discussed with each patient's own treating physicians.

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Important Note: This site is not intended to offer medical advice. Every patient is different, and only your personal physician can help to counsel you about what is best for your situation. What we offer is general reference information about various disorders and treatments for your education.

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