Intracerebral Hemorrhage
Intracerebral Hemorrhage (ICH)
ICH is most commonly caused by hypertension, aneurysm/arteriovenous malformations rupture or head trauma. Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and relieving the pressure on the brain.
What is an intracerebral hemorrhage (ICH)?
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.
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 known as IVH(Intraventricular Hemorrhage).
What are the symptoms?
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 Aspirin, Clopidogrel, 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 or weakening 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.
- 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. Advancing age and hypertension are the most important risk factors for ICH. Approximately 70% of patients experience long-term deficits after an ICH.
How is a diagnosis made?
Following diagnostic tests will help determine the source of the bleeding.
Computed Tomography (CT) scan is a noninvasive X-ray to review the anatomical structures within the brain and to detect any bleeding. CT angiography involves the injection of contrast into the bloodstream to view arteries of the brain.
Magnetic Resonance Imaging (MRI) scan is a noninvasive test, which uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues of your brain. An MRA (Magnetic Resonance Angiogram) involves the injection of contrast into the bloodstream to examine the blood vessels as well as the structures of the brain.
DSA (Digital Subtraction Angiography) is an invasive procedure, where a catheter is inserted into an artery and passed through the blood vessels to the brain. Once the catheter is in place, contrast dye is injected into the bloodstream and X-rays are taken.
What treatments are available?
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. 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.
- If the patient was on blood thinners, reversal drugs will be given to restore clotting factors.
- Blood pressure is managed to decrease the risk of more bleeding yet provide enough blood flow (perfusion) to the brain.
- Controlling intracranial pressure is a factor in large bleeds. A device called an ICP monitor may be placed directly into the ventricles or within the brain to measure pressure. Normal ICP is 20mm HG.
- Removing cerebrospinal fluid (CSF) from the ventricles helps control pressure. A ventricular catheter (VP shunt) may be placed to drain CSF fluid and allow room for the hematoma to expand without damaging the brain.
- Hyperventilation also helps control ICP. In some cases, coma may be induced with drugs to bring down ICP.
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.
- Craniotomyinvolves cutting a hole in the skull with a drill to expose the brain and remove the clot. Because of the increased risk to the brain, this technique is usually used only when the hematoma is close to the surface of the brain or if it is associated with an AVM or tumor that must also be removed.
- Stereotactic clot aspiration is a minimally invasive surgery for large hematomas located deep inside the brain. The procedure uses a stereotactic frame to guide a needle or endoscope directly into the hematoma.
- 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.
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