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Intracerebral Hemorrhage (ICH)

 

        

What is an intracerebral hemorrhage?

Tiny arteries bring blood to areas deep inside the brain. High blood pressure (hypertension) can cause these thin-walled arteries to rupture, releasing blood into the brain tissue. Enclosed within the rigid skull, clotted blood and fluid buildup increases pressure that can crush the brain against the bone or cause it to shift and herniate. As blood spills into the brain, the area that artery supplied is now deprived of oxygen-rich blood – called a stroke. As blood cells within the clot die, toxins are released that further damage brain cells in the area surrounding the hematoma.

An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep hemorrhages can expand into the ventricles – the fluid filled spaces in the center of the brain. Blockage of the normal cerebrospinal (CSF) circulation can enlarge the ventricles (hydrocephalus) causing confusion, lethargy, and loss of consciousness.

What are the symptoms?

If you experience symptoms of an ICH, call 911 immediately! Symptoms usually come on suddenly and can vary depending on the location of the bleed. Common symptoms include:

  • Headache, nausea, and vomiting
  • Lethargy or confusion
  • Sudden weakness or numbness of the face, arm or leg, usually on one side
  • Loss of consciousness
  • Temporary loss of vision
  • Seizures

What are the causes?

  • Hypertension: elevated blood pressure may cause tiny arteries to burst inside the brain. Normal pressure is 120/80 mm Hg.
  • Blood thinners: drugs such as coumadin, heparin, and warfarin used to prevent clots in heart and stroke conditions may cause ICH.
  • AVM: a tangle of abnormal arteries and veins with no capillaries in between.
  • Aneurysm: a bulge of an artery wall.
  • Head trauma: fractures to the skull and penetrating wounds (gunshot) can damage an artery and cause bleeding.
  • Bleeding disorders: hemophilia, sickle cell anemia, DIC, thrombocytopenia.
  • Tumors: highly vascular tumors such as angiomas and metastatic tumors can bleed into the brain tissue.
  • Amyloid angiopathy: a buildup of protein within the walls of arteries.
  • Drug usage: alcohol, cocaine and other illicit drugs can cause ICH.
  • Spontaneous: ICH by unknown causes.

Who is affected?

Ten percent of strokes are caused by ICH. ICH is twice as common as subarachnoid hemorrhage (SAH) and has a 40% risk of death. ICH occurs slightly more frequently among men than women and is more common among young and middle-aged African Americans and Japanese. Advancing age and hypertension are the most important risk factors for ICH. Approximately 70% of patients experience long-term deficits after an ICH.

Who is a diagnosis made?

When a person is brought to the emergency room with a suspected brain hemorrhage, doctors will learn as much about their symptoms, current and previous medical problems, medications, and family history. The person’s condition is assessed quickly. Diagnostic tests will help determine the source of the bleeding. Tests that may be conducted include:

  • CT scan
  • MRI scan
  • Angiogram

What treatments are available?

Treatment may include lifesaving measures, symptom relief, and complication prevention. Once the cause and location of the bleeding is identified, medical or surgical treatment is performed to stop the bleeding, remove the clot, and relieve the pressure on the brain. If left alone the brain will eventually absorb the clot within a couple weeks – however the damage to the brain caused by ICP and blood toxins may be irreversible.

Generally, patients with small hemorrhages (<10 cm3) and minimal deficits are treated medically. Patients with cerebellar hemorrhages (>3 cm3) who are deteriorating or who have brainstem compression and hydrocephalus are treated surgically to remove the hematoma as soon as possible. Patients with large lobar hemorrhages (50 cm3) who are deteriorating usually undergo surgical removal of the hematoma.

  • Medical treatment: the patient will stay in the stroke unit or intensive care unit (ICU) for close monitoring and care.
  • Surgical treatment: the goal of surgery is to remove as much of the blood clot as possible and stop the source of bleeding if it is from an identifiable cause such as an AVM or tumor. Depending on the location of the clot either a craniotomy or a stereotactic aspiration may be performed.

Recovery and prevention:

Immediately after an ICH, the patient will stay in the intensive care unit (ICU) for several weeks where doctors and nurses watch them closely for signs of rebleeding, hydrocephalus, and other complications. Once their condition is stable, the patient is transferred to a regular room.

ICH patients may suffer short-term and/or long-term deficits as a result of the bleed or the treatment. Some of these deficits may disappear over time with healing and therapy. The recovery process may take weeks, months, or years to understand the level of deficits incurred and regain function.

Clinical trials:

Clinical trials are research studies in which new treatments are tested in people to see if they are safe and effective. Studies can be sponsored by the National Institute of Health (clinicaltrials.gov) as well as private industry and pharmaceutical companies (www.centerwatch.com).

If you would like to schedule an appointment with one of your Spine specialists or have any questions, please call 515.875.9560.