{{pp|small=yes}} {{short description|Type of intracranial bleeding that occurs within the brain tissue itself}} {{cs1 config|name-list-style=vanc}} {{Infobox medical condition (new) | name = Intracerebral hemorrhage | image = Intracerebral hemorrage (CT scan).jpg | caption = CT scan of a spontaneous intracerebral bleed, leaking into the lateral ventricles | field = Neurosurgery, neurocritical care | synonyms = Cerebral haemorrhage, cerebral hemorrhage, intra-axial hemorrhage, cerebral hematoma, cerebral bleed, brain bleed, hemorrhagic stroke | symptoms = Headache, one-sided numbness, weakness, tingling, or paralysis, speech problems, vision or hearing problems, dizziness or lightheadedness or vertigo, nausea/vomiting, seizures, decreased level or total loss of consciousness, neck stiffness, memory loss, attention and coordination problems, balance problems, fever, shortness of breath (when bleed is in the brain stem) <ref name=Hem2015/><ref name=Ca2012/> | complications = Coma, persistent vegetative state, cardiac arrest (when bleeding is severe or in the brain stem), death | onset = | duration = | types = | causes = Brain trauma, aneurysms, arteriovenous malformations, brain tumors, hemorrhagic conversion of ischemic stroke<ref name=Hem2015/> | risks = High blood pressure, diabetes, high cholesterol, amyloidosis, alcoholism, low cholesterol, blood thinners, cocaine use<ref name=Ca2012/> | diagnosis = CT scan<ref name=Hem2015/> | differential = Ischemic stroke<ref name=Hem2015/> | prevention = | treatment = Blood pressure control, surgery, ventricular drain<ref name=Hem2015/> | medication = | prognosis = 20% good outcome<ref name=Ca2012/> | frequency = 2.5 per 10,000 people a year<ref name=Ca2012/> | deaths = 44% die within one month<ref name=Ca2012/> }} <!-- Definition and symptoms -->
'''Intracerebral hemorrhage''' ('''ICH'''), also known as '''hemorrhagic stroke''', is a sudden bleeding into the tissues of the brain (i.e. the parenchyma), into its ventricles, or into both.<ref name="clevelandclinic">{{Cite web|url=https://my.clevelandclinic.org/health/diseases/14480-brain-bleed-hemorrhage-intracranial-hemorrhage|title=Brain Bleed/Hemorrhage (Intracranial Hemorrhage): Causes, Symptoms, Treatment}}</ref><ref name="Naidichet2012">{{cite book| vauthors = Naidich TP, Castillo M, Cha S, Smirniotopoulos JG |title=Imaging of the Brain, Expert Radiology Series,1: Imaging of the Brain|date=2012|publisher=Elsevier Health Sciences|isbn=978-1-4160-5009-4|page=387|url=https://books.google.com/books?id=TUfZSKldJRwC&pg=PA387|language=en|url-status=live|archive-url=https://web.archive.org/web/20161002094230/https://books.google.com/books?id=TUfZSKldJRwC&pg=PA387|archive-date=2016-10-02}}</ref><ref name="Hem2015">{{cite journal |display-authors=6 |vauthors=Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D |date=July 2015 |title=Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association |journal=Stroke |volume=46 |issue=7 |pages=2032–2060 |doi=10.1161/str.0000000000000069 |pmid=26022637 |doi-access=free |collaboration=Council on Clinical Cardiology; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing}}</ref> An ICH is a type of bleeding within the skull and one kind of stroke (ischemic stroke being the other).<ref name="clevelandclinic" /><ref name="Naidichet2012" /> Symptoms can vary dramatically depending on the severity (how much blood), acuity (over what timeframe), and location (anatomically) but can include headache, one-sided weakness, numbness, tingling, or paralysis, speech problems, vision or hearing problems, memory loss, attention problems, coordination problems, balance problems, dizziness or lightheadedness or vertigo, nausea/vomiting, seizures, decreased level of consciousness or total loss of consciousness, neck stiffness, and fever.<ref name="Ca2012" /><ref name="Hem2015" />
<!-- Cause and diagnosis --> Hemorrhagic stroke may occur on the background of alterations to the blood vessels in the brain, such as cerebral arteriolosclerosis, cerebral amyloid angiopathy, cerebral arteriovenous malformation, brain trauma, brain tumors and an intracranial aneurysm, which can cause intraparenchymal or subarachnoid hemorrhage.<ref name=Hem2015/>
The biggest risk factors for spontaneous bleeding are high blood pressure and amyloidosis.<ref name="Ca2012" /> Other risk factors include alcoholism, low cholesterol, blood thinners, and cocaine use.<ref name="Ca2012" /> Diagnosis is typically by CT scan.<ref name="Hem2015" />
<!-- Prevention and treatment --> Treatment should typically be carried out in an intensive care unit due to strict blood pressure goals and frequent use of both pressors and antihypertensive agents.<ref name="Hem2015" /><ref>{{cite journal | vauthors = Ko SB, Yoon BW | title = Blood Pressure Management for Acute Ischemic and Hemorrhagic Stroke: The Evidence | journal = Seminars in Respiratory and Critical Care Medicine | volume = 38 | issue = 6 | pages = 718–725 | date = December 2017 | pmid = 29262429 | doi = 10.1055/s-0037-1608777 | doi-access = free }}</ref> Anticoagulation should be reversed if possible and blood sugar kept in the normal range.<ref name="Hem2015" /> A procedure to place an external ventricular drain may be used to treat hydrocephalus or increased intracranial pressure, however, the use of corticosteroids is frequently avoided.<ref name="Hem2015" /> Sometimes surgery to directly remove the blood can be therapeutic.<ref name="Hem2015" />
<!-- Epidemiology, prognosis, and history--> Cerebral bleeding affects about 2.5 per 10,000 people each year.<ref name=Ca2012/> It occurs more often in males and older people.<ref name=Ca2012/> About 44% of those affected die within a month.<ref name=Ca2012/> A good outcome occurs in about 20% of those affected.<ref name=Ca2012>{{cite journal | vauthors = Caceres JA, Goldstein JN | title = Intracranial hemorrhage | journal = Emergency Medicine Clinics of North America | volume = 30 | issue = 3 | pages = 771–794 | date = August 2012 | pmid = 22974648 | pmc = 3443867 | doi = 10.1016/j.emc.2012.06.003 }}</ref> Intracerebral hemorrhage, a type of hemorrhagic stroke, was first distinguished from ischemic strokes due to insufficient blood flow, so called "leaks and plugs", in 1823.<ref name="Henn2003">{{cite book |url=https://books.google.com/books?id=RG6be-FhMxEC&pg=PA1 |title=Imaging in Stroke |vauthors=Hennerici M |date=2003 |publisher=Remedica |isbn=978-1-901346-25-1 |page=1 |language=en |archive-url=https://web.archive.org/web/20161002095126/https://books.google.com/books?id=RG6be-FhMxEC&pg=PA1 |archive-date=2016-10-02 |url-status=live}}</ref>
== Epidemiology == The incidence of intracerebral hemorrhage is estimated at 24.6 cases per 100,000 person years with the incidence rate being similar in men and women.<ref name="NEJM Sheth" /><ref name="Lancet Neurology, epidemiology">{{cite journal |vauthors=van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ |date=February 2010 |title=Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis |journal=The Lancet. Neurology |volume=9 |issue=2 |pages=167–176 |doi=10.1016/S1474-4422(09)70340-0 |pmid=20056489 |s2cid=25364307}}</ref> The incidence is much higher in the elderly, especially those who are 85 or older, who are 9.6 times more likely to have an intracerebral hemorrhage as compared to those of middle age.<ref name="Lancet Neurology, epidemiology" /> It accounts for 20% of all cases of cerebrovascular disease in the United States, behind cerebral thrombosis (40%) and cerebral embolism (30%).<ref>Page 117 in: {{cite book |title=Neurology practice guidelines |vauthors=Schutta HS, Lechtenberg R |publisher=M. Dekker |year=1998 |isbn=978-0-8247-0104-8 |location=New York}}</ref>
== Types == {{See also|Subarachnoid hemorrhage}}
=== Intraparenchymal hemorrhage === Intraparenchymal hemorrhage (IPH) is one form of intracerebral bleeding in which there is bleeding within brain parenchyma.<ref name=":1" /> Intraparenchymal hemorrhage accounts for approximately 8-13% of all strokes and results from a wide spectrum of disorders. It is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage, and therefore constitutes an immediate medical emergency. Intracerebral hemorrhages and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.
=== Intraventricular hemorrhage === Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma or from hemorrhagic stroke.
30% of intraventricular hemorrhage (IVH) are primary, confined to the ventricular system and typically caused by intraventricular trauma, aneurysm, vascular malformations, or tumors, particularly of the choroid plexus.<ref name=":2" /> However 70% of IVH are secondary in nature, resulting from an expansion of an existing intraparenchymal or subarachnoid hemorrhage.<ref name=":2" /> Intraventricular hemorrhage has been found to occur in 35% of moderate to severe traumatic brain injuries.<ref name=":3" /> Thus the hemorrhage usually does not occur without extensive associated damage, and so the outcome is rarely good.<ref name=":4" /><ref name=":5" />
==Signs and symptoms== People with intracerebral bleeding have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed.<ref name="Vinas and Pilistis">{{cite web | vauthors = Vinas FC, Pilitsis J | date = 2006 | url = http://www.emedicine.com/med/topic2888.htm | title = Penetrating Head Trauma | archive-url = https://web.archive.org/web/20050913061516/http://www.emedicine.com/med/topic2888.htm | archive-date=2005-09-13 | work = Emedicine.com }}</ref> These localizing signs and symptoms can include hemiplegia (or weakness localized to one side of the body) and paresthesia (loss of sensation) including hemisensory loss (if localized to one side of the body).<ref name="NEJM Sheth" /> These symptoms are usually rapid in onset, sometimes occurring in minutes, but not as rapid as the symptom onset in ischemic stroke.<ref name="NEJM Sheth" /> While the duration of onset may not be as rapid, it is important that patients go to the emergency department as soon as they notice any symptoms as early detection and management of stroke may lead to better outcomes post-stroke than delayed identification.<ref>{{cite journal | vauthors = Colton K, Richards CT, Pruitt PB, Mendelson SJ, Holl JL, Naidech AM, Prabhakaran S, Maas MB | display-authors = 6 | title = Early Stroke Recognition and Time-based Emergency Care Performance Metrics for Intracerebral Hemorrhage | journal = Journal of Stroke and Cerebrovascular Diseases | volume = 29 | issue = 2 | article-number = 104552 | date = February 2020 | pmid = 31839545 | pmc = 6954314 | doi = 10.1016/j.jstrokecerebrovasdis.2019.104552 }}</ref>
A mnemonic to remember the warning signs of stroke is FAST (facial droop, arm weakness, speech difficulty, and time to call emergency services),<ref>{{cite journal | vauthors = Harbison J, Massey A, Barnett L, Hodge D, Ford GA | title = Rapid ambulance protocol for acute stroke | journal = Lancet | volume = 353 | issue = 9168 | page = 1935 | date = June 1999 | pmid = 10371574 | doi = 10.1016/S0140-6736(99)00966-6 | s2cid = 36692451 }}</ref> as advocated by the Department of Health (United Kingdom) and the Stroke Association, the American Stroke Association, the National Stroke Association (US), the Los Angeles Prehospital Stroke Screen (LAPSS)<ref>{{cite journal | vauthors = Kidwell CS, Saver JL, Schubert GB, Eckstein M, Starkman S | title = Design and retrospective analysis of the Los Angeles Prehospital Stroke Screen (LAPSS) | journal = Prehospital Emergency Care | volume = 2 | issue = 4 | pages = 267–273 | date = January 1998 | pmid = 9799012 | doi = 10.1080/10903129808958878 }}</ref> and the Cincinnati Prehospital Stroke Scale (CPSS).<ref>{{cite journal | vauthors = Kothari RU, Pancioli A, Liu T, Brott T, Broderick J | title = Cincinnati Prehospital Stroke Scale: reproducibility and validity | journal = Annals of Emergency Medicine | volume = 33 | issue = 4 | pages = 373–378 | date = April 1999 | pmid = 10092713 | doi = 10.1016/S0196-0644(99)70299-4 }}</ref> Use of these scales is recommended by professional guidelines.<ref>{{Cite journal | vauthors = Meredith TL, Freed N, Soulsby C, Bay S |date=2009 |title=Clinical audit to assess implications of implementing National Institute for Health and Clinical Excellence (NICE) guideline 32: Department of Nutrition and Dietetics at Barts and the London National Health Service (NHS) Trust 2007 |journal=Proceedings of the Nutrition Society |volume=68 |issue=OCE1 |article-number=E67 |doi=10.1017/s0029665109002080 |issn=0029-6651|doi-access=free }}</ref> FAST is less reliable in the recognition of posterior circulation stroke.<ref>{{cite journal | vauthors = Merwick Á, Werring D | title = Posterior circulation ischaemic stroke | journal = BMJ | volume = 348 | issue = may19 33 | article-number = g3175 | date = May 2014 | pmid = 24842277 | doi = 10.1136/bmj.g3175 | doi-access = free }}</ref>
Other symptoms include those that indicate a rise in intracranial pressure caused by a large mass (due to hematoma expansion) putting pressure on the brain.<ref name="Vinas and Pilistis" /> These symptoms include headaches, nausea, vomiting, a depressed level of consciousness, stupor and death.<ref name="NEJM Sheth" /> Continued elevation in the intracranial pressure and the accompanying mass effect may eventually cause brain herniation (when different parts of the brain are displaced or shifted to new areas in relation to the skull and surrounding dura mater supporting structures). Brain herniation is associated with hyperventilation, extensor rigidity, pupillary asymmetry, pyramidal signs, coma and death.<ref name=":1">{{cite journal | vauthors = Kalita J, Misra UK, Vajpeyee A, Phadke RV, Handique A, Salwani V | title = Brain herniations in patients with intracerebral hemorrhage | journal = Acta Neurologica Scandinavica | volume = 119 | issue = 4 | pages = 254–260 | date = April 2009 | pmid = 19053952 | doi = 10.1111/j.1600-0404.2008.01095.x | s2cid = 21870062 | doi-access = free }}</ref>
Hemorrhage into the basal ganglia or thalamus causes contralateral hemiplegia due to damage to the internal capsule.<ref name="NEJM Sheth" /> Other possible symptoms include gaze palsies or hemisensory loss.<ref name="NEJM Sheth" /> Intracerebral hemorrhage into the cerebellum may cause ataxia, vertigo, incoordination of limbs, and vomiting.<ref name="NEJM Sheth" /> Some cases of cerebellar hemorrhage lead to blockage of the fourth ventricle with subsequent impairment of drainage of cerebrospinal fluid from the brain.<ref name="NEJM Sheth" /> The ensuing hydrocephalus, or fluid buildup in the ventricles of the brain leads to a decreased level of consciousness, total loss of consciousness, coma, and persistent vegetative state.<ref name="NEJM Sheth" /> Brainstem hemorrhage most commonly occurs in the pons and is associated with shortness of breath, cranial nerve palsies, pinpoint (but reactive) pupils, gaze palsies, facial weakness, coma, and persistent vegetative state (if there is damage to the reticular activating system).<ref name="NEJM Sheth" />
==Causes== [[File:Posterior fossa hemorrhage.jpg|thumb|right|Axial CT scan showing hemorrhage in the posterior fossa<ref name="Yadav07">{{cite journal | vauthors = Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A | title = Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus | journal = BMC Neurology | volume = 7 | article-number = 1 | date = January 2007 | pmid = 17204141 | pmc = 1780056 | doi = 10.1186/1471-2377-7-1 | doi-access = free }}</ref>]] Intracerebral bleeds are the second most common cause of stroke, accounting for 10% of hospital admissions for stroke.<ref name="pmid23239837">{{cite journal | vauthors = Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D, Turner MB | display-authors = 6 | title = Heart disease and stroke statistics--2013 update: a report from the American Heart Association | journal = Circulation | volume = 127 | issue = 1 | pages = e6–e245 | date = January 2013 | pmid = 23239837 | pmc = 5408511 | doi = 10.1161/CIR.0b013e31828124ad | bibcode = 2013Circu.127124adG }}</ref> High blood pressure raises the risks of spontaneous intracerebral hemorrhage by two to six times.<ref name="Yadav07"/> More common in adults than in children, intraparenchymal bleeds are usually due to penetrating head trauma, but can also be due to depressed skull fractures. Acceleration-deceleration trauma,<ref name="McCaffrey">{{cite web | vauthors = McCaffrey P | date = 2001 | url = http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html | work = The Neuroscience on the Web Series | title = CMSD 336 Neuropathologies of Language and Cognition | archive-url = https://web.archive.org/web/20051125040437/http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html | archive-date=2005-11-25 | publisher = California State University | location = Chico | access-date = 19 June 2007 }}</ref><ref name="Orlando Regional Healthcare">{{cite web | work = Orlando Regional Healthcare, Education and Development | date = 2004 | url = http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf | title = Overview of Adult Traumatic Brain Injuries | archive-url = https://web.archive.org/web/20080227162001/http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf | archive-date=2008-02-27 | access-date = 2008-01-16 }}</ref><ref name="Shepherd">{{cite web | vauthors = Shepherd S | date = 2004 | url = http://www.emedicine.com/med/topic2820.htm | title = Head Trauma | archive-url = https://web.archive.org/web/20051026012843/http://www.emedicine.com/med/topic2820.htm | archive-date=2005-10-26 | work = Emedicine.com | access-date = 19 June 2007 }}</ref> rupture of an aneurysm or arteriovenous malformation (AVM), and bleeding within a tumor are additional causes. Amyloid angiopathy is not an uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis.{{citation needed|date=February 2021}}
Risk factors for ICH include:<ref name=":2">{{cite journal | vauthors = Feldmann E, Broderick JP, Kernan WN, Viscoli CM, Brass LM, Brott T, Morgenstern LB, Wilterdink JL, Horwitz RI | display-authors = 6 | title = Major risk factors for intracerebral hemorrhage in the young are modifiable | journal = Stroke | volume = 36 | issue = 9 | pages = 1881–1885 | date = September 2005 | pmid = 16081867 | doi = 10.1161/01.str.0000177480.62341.6b | doi-access = free }}</ref> * Hypertension (high blood pressure) * Diabetes mellitus * Menopause * Excessive alcohol consumption * Severe migraine
Hypertension is the strongest risk factor associated with intracerebral hemorrhage and long term control of elevated blood pressure has been shown to reduce the incidence of hemorrhage.<ref name="NEJM Sheth">{{cite journal | vauthors = Sheth KN | title = Spontaneous Intracerebral Hemorrhage | journal = The New England Journal of Medicine | volume = 387 | issue = 17 | pages = 1589–1596 | date = October 2022 | pmid = 36300975 | doi = 10.1056/NEJMra2201449 | s2cid = 253159180 }}</ref> Cerebral amyloid angiopathy, a disease characterized by deposition of amyloid beta peptides in the walls of the small blood vessels of the brain, leading to weakened blood vessel walls and an increased risk of bleeding; is also an important risk factor for the development of intracerebral hemorrhage. Other risk factors include advancing age (usually with a concomitant increase of cerebral amyloid angiopathy risk in the elderly), use of anticoagulants or antiplatelet medications, the presence of cerebral microbleeds, chronic kidney disease, and low low density lipoprotein (LDL) levels (usually below 70).<ref name="Neurology, LDL">{{cite journal | vauthors = Ma C, Gurol ME, Huang Z, Lichtenstein AH, Wang X, Wang Y, Neumann S, Wu S, Gao X | display-authors = 6 | title = Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage: A prospective study | journal = Neurology | volume = 93 | issue = 5 | pages = e445–e457 | date = July 2019 | pmid = 31266905 | pmc = 6693427 | doi = 10.1212/WNL.0000000000007853 }}</ref><ref name="An risk factors">{{cite journal | vauthors = An SJ, Kim TJ, Yoon BW | title = Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update | journal = Journal of Stroke | volume = 19 | issue = 1 | pages = 3–10 | date = January 2017 | pmid = 28178408 | pmc = 5307940 | doi = 10.5853/jos.2016.00864 }}</ref> The direct oral anticoagulants (DOACs) such as the factor Xa inhibitors or direct thrombin inhibitors are thought to have a lower risk of intracerebral hemorrhage as compared to the vitamin K antagonists such as warfarin.<ref name="NEJM Sheth" />
Cigarette smoking may be a risk factor but the association is weak.<ref>{{cite book | vauthors = Carhuapoma JR, Mayer SA, Hanley DF |author2-link=Stephan A. Mayer |title=Intracerebral Hemorrhage |date=2009 |publisher=Cambridge University Press |isbn=978-0-521-87331-4 |page=6 |url=https://books.google.com/books?id=qSomK2zPbEwC&dq=Intracerebral+Hemorrhage+smoking&pg=PA6 |language=en}}</ref>
Traumatic intracerebral hematomas are divided into acute and delayed. Acute intracerebral hematomas occur at the time of the injury while delayed intracerebral hematomas have been reported from as early as 6 hours post injury to as long as several weeks.{{citation needed|date=February 2021}}
==Diagnosis== [[File:Intracerebral hemorrhage.jpg|thumb|Spontaneous ICH with hydrocephalus on CT scan<ref name="Yadav07"/>]] Both computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been proved to be effective in diagnosing intracranial vascular malformations after ICH.<ref name=":3">{{cite journal | vauthors = Josephson CB, White PM, Krishan A, Al-Shahi Salman R | title = Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 9 | article-number = CD009372 | date = September 2014 | pmid = 25177839 | pmc = 6544803 | doi = 10.1002/14651858.CD009372.pub2 }}</ref> So frequently, a CT angiogram will be performed in order to exclude a secondary cause of hemorrhage<ref name=":0">{{cite journal | vauthors = Yeung R, Ahmad T, Aviv RI, de Tilly LN, Fox AJ, Symons SP | title = Comparison of CTA to DSA in determining the etiology of spontaneous ICH | journal = The Canadian Journal of Neurological Sciences. Le Journal Canadien des Sciences Neurologiques | volume = 36 | issue = 2 | pages = 176–180 | date = March 2009 | pmid = 19378710 | doi = 10.1017/s0317167100006533 | doi-access = free }}</ref> or to detect a "spot sign".
Intraparenchymal hemorrhage can be recognized on CT scans because blood appears brighter than other tissue and is separated from the inner table of the skull by brain tissue. The tissue surrounding a bleed is often less dense than the rest of the brain because of edema, and therefore shows up darker on the CT scan.<ref name=":0" /> The oedema surrounding the haemorrhage would rapidly increase in size in the first 48 hours, and reached its maximum extent at day 14. The bigger the size of the haematoma, the larger its surrounding oedema.<ref name="pmid21164136">{{cite journal | vauthors = Venkatasubramanian C, Mlynash M, Finley-Caulfield A, Eyngorn I, Kalimuthu R, Snider RW, Wijman CA | title = Natural history of perihematomal edema after intracerebral hemorrhage measured by serial magnetic resonance imaging | journal = Stroke | volume = 42 | issue = 1 | pages = 73–80 | date = January 2011 | pmid = 21164136 | pmc = 3074599 | doi = 10.1161/STROKEAHA.110.590646 }}</ref> Brain oedema formation is due to the breakdown of red blood cells, where haemoglobin and other contents of red blood cells are released. The release of these red blood cells contents causes toxic effect on the brain and causes brain oedema. Besides, the breaking down of blood-brain barrier also contributes to the odema formation.<ref name=":4">{{cite journal | vauthors = Xi G, Hua Y, Bhasin RR, Ennis SR, Keep RF, Hoff JT | title = Mechanisms of edema formation after intracerebral hemorrhage: effects of extravasated red blood cells on blood flow and blood-brain barrier integrity | journal = Stroke | volume = 32 | issue = 12 | pages = 2932–2938 | date = December 2001 | pmid = 11739998 | doi = 10.1161/hs1201.099820 | s2cid = 7089563 }}</ref>
Apart from CT scans, haematoma progression of intracerebral haemorrhage can be monitored using transcranial ultrasound. Ultrasound probe can be placed at the temporal lobe to estimate the volume of haematoma within the brain, thus identifying those with active bleeding for further intervention to stop the bleeding. Using ultrasound can also reduces radiation risk to the subject from CT scans.<ref name=":5">{{cite journal | vauthors = Ovesen C, Christensen AF, Krieger DW, Rosenbaum S, Havsteen I, Christensen H | title = Time course of early postadmission hematoma expansion in spontaneous intracerebral hemorrhage | journal = Stroke | volume = 45 | issue = 4 | pages = 994–999 | date = April 2014 | pmid = 24627116 | doi = 10.1161/STROKEAHA.113.003608 | s2cid = 7716659 | doi-access = free }}</ref>
=== Location === When due to high blood pressure, intracerebral hemorrhages typically occur in the putamen (50%) or thalamus (15%), cerebrum (10–20%), cerebellum (10–13%), pons (7–15%), or elsewhere in the brainstem (1–6%).<ref>{{cite book | vauthors = Greenberg MS |title= Handbook of Neurosurgery |date= 2016|publisher= Thieme |isbn= 978-1-62623-241-9}}</ref><ref>{{cite book| vauthors = Prayson RA |title=Neuropathology |date=2012 |publisher=Elsevier Health Sciences |isbn=978-1-4377-0949-0|page=49|url=https://books.google.com/books?id=DmNSdcu14HEC&pg=PA49|language=en|url-status=live|archive-url=https://web.archive.org/web/20170312043001/https://books.google.com/books?id=DmNSdcu14HEC&pg=PA49|archive-date=2017-03-12}}</ref>
==Treatment== Treatment depends substantially on the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery. * Tracheal intubation is indicated in people with decreased level of consciousness or other risk of airway obstruction.<ref name=emedicine/> * IV fluids are given to maintain fluid balance, using isotonic rather than hypotonic fluids.<ref name=emedicine/>
===Medications=== Rapid lowering of the blood pressure using antihypertensive therapy for those with hypertensive emergency can have higher functional recovery at 90 days post intracerebral haemorrhage, when compared to those who undergone other treatments such as mannitol administration, reversal of anticoagulation (those previously on anticoagulant treatment for other conditions), surgery to evacuate the haematoma, and standard rehabilitation care in hospital, while showing similar rate of death at 12%.<ref>{{cite journal | vauthors = Anderson CS, Qureshi AI | title = Implications of INTERACT2 and other clinical trials: blood pressure management in acute intracerebral hemorrhage | journal = Stroke | volume = 46 | issue = 1 | pages = 291–295 | date = January 2015 | pmid = 25395408 | doi = 10.1161/STROKEAHA.114.006321 | s2cid = 45730236 | doi-access = free }}</ref> Early lowering of the blood pressure can reduce the volume of the haematoma, but may not have any effect against the oedema surrounding the haematoma.<ref>{{cite journal | vauthors = Anderson CS, Huang Y, Arima H, Heeley E, Skulina C, Parsons MW, Peng B, Li Q, Su S, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Morgenstern LB, Chalmers J, Wang JG | display-authors = 6 | title = Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT) | journal = Stroke | volume = 41 | issue = 2 | pages = 307–312 | date = February 2010 | pmid = 20044534 | doi = 10.1161/STROKEAHA.109.561795 | s2cid = 5871420 | doi-access = free }}</ref> Reducing the blood pressure rapidly does not cause brain ischemia in those who have intracerebral haemorrhage.<ref>{{cite journal | vauthors = Butcher KS, Jeerakathil T, Hill M, Demchuk AM, Dowlatshahi D, Coutts SB, Gould B, McCourt R, Asdaghi N, Findlay JM, Emery D, Shuaib A | display-authors = 6 | title = The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial | journal = Stroke | volume = 44 | issue = 3 | pages = 620–626 | date = March 2013 | pmid = 23391776 | doi = 10.1161/STROKEAHA.111.000188 | s2cid = 54488358 | doi-access = free }}</ref> The American Heart Association and American Stroke Association guidelines in 2015 recommended decreasing the blood pressure to a SBP of 140 mmHg.<ref name=Hem2015/> However, later reviews found unclear difference between intensive and less intensive blood pressure control.<ref name="pmid26242330">{{cite journal | vauthors = Ma J, Li H, Liu Y, You C, Huang S, Ma L | title = Effects of Intensive Blood Pressure Lowering on Intracerebral Hemorrhage Outcomes: A Meta-Analysis of Randomized Controlled Trials | journal = Turkish Neurosurgery | volume = 25 | issue = 4 | pages = 544–551 | date = 2015 | pmid = 26242330 | doi = 10.5137/1019-5149.JTN.9270-13.0 | doi-broken-date = 1 July 2025 }}</ref><ref>{{cite journal | vauthors = Boulouis G, Morotti A, Goldstein JN, Charidimou A | title = Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 88 | issue = 4 | pages = 339–345 | date = April 2017 | pmid = 28214798 | doi = 10.1136/jnnp-2016-315346 | s2cid = 25397701 }}</ref>
Giving Factor VIIa within 4 hours limits the bleeding and formation of a hematoma. However, it also increases the risk of thromboembolism.<ref name=emedicine>{{cite web | url = http://emedicine.medscape.com/article/1163977-treatment | work = eMedicine Specialties > Neurology > Neurological Emergencies | title = Intracranial Haemorrhage: Treatment & Medication | archive-url = https://web.archive.org/web/20090312093658/http://emedicine.medscape.com/article/1163977-treatment | archive-date=2009-03-12 | vauthors = Liebeskind DS | date = 7 August 2006 }}</ref> It thus overall does not result in better outcomes in those without hemophilia.<ref>{{cite journal | vauthors = Yuan ZH, Jiang JK, Huang WD, Pan J, Zhu JY, Wang JZ | title = A meta-analysis of the efficacy and safety of recombinant activated factor VII for patients with acute intracerebral hemorrhage without hemophilia | journal = Journal of Clinical Neuroscience | volume = 17 | issue = 6 | pages = 685–693 | date = June 2010 | pmid = 20399668 | doi = 10.1016/j.jocn.2009.11.020 | s2cid = 30590573 }}</ref>
Frozen plasma, vitamin K, protamine, or platelet transfusions may be given in case of a coagulopathy.<ref name=emedicine/> Platelets however appear to worsen outcomes in those with spontaneous intracerebral bleeding on antiplatelet medication.<ref>{{Cite journal |last1=Eilertsen |first1=Helle |last2=Menon |first2=Chaamanti S. |last3=Law |first3=Zhe Kang |last4=Chen |first4=Chen |last5=Bath |first5=Philip M. |last6=Steiner |first6=Thorsten |last7=Desborough |first7=Michael Jr |last8=Sandset |first8=Else C. |last9=Sprigg |first9=Nikola |last10=Al-Shahi Salman |first10=Rustam |date=2023-10-23 |title=Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=10 |article-number=CD005951 |doi=10.1002/14651858.CD005951.pub5 |issn=1469-493X |pmid=37870112|pmc=10591281 }}</ref>
The specific reversal agents idarucizumab and andexanet alfa may be used to stop continued intracerebral hemorrhage in people taking directly oral acting anticoagulants (such as factor Xa inhibitors or direct thrombin inhibitors).<ref name="NEJM Sheth" /> However, if these specialized medications are not available, prothrombin complex concentrate may also be used.<ref name="NEJM Sheth" />
Only 7% of those with ICH are presented with clinical features of seizures while up to 25% of those have subclinical seizures. Seizures are not associated with an increased risk of death or disability. Meanwhile, anticonvulsant administration can increase the risk of death. Therefore, anticonvulsants are only reserved for those that have shown obvious clinical features of seizures or seizure activity on electroencephalography (EEG).<ref>{{cite journal | vauthors = Fogarty Mack P | title = Intracranial haemorrhage: therapeutic interventions and anaesthetic management | journal = British Journal of Anaesthesia | volume = 113 | issue = Suppl 2 | pages = ii17–ii25 | date = December 2014 | pmid = 25498578 | doi = 10.1093/bja/aeu397 | doi-access = free }}</ref>
H2 antagonists or proton pump inhibitors are commonly given to try to prevent stress ulcers, a condition linked with ICH.<ref name=emedicine/>
Corticosteroids were thought to reduce swelling. However, in large controlled studies, corticosteroids have been found to increase mortality rates and are no longer recommended.<ref>{{cite journal | vauthors = Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloë V, Muñoz-Sánchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P | display-authors = 6 | title = Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial | journal = Lancet | volume = 364 | issue = 9442 | pages = 1321–1328 | date = 9 October 2016 | pmid = 15474134 | doi = 10.1016/S0140-6736(04)17188-2 | s2cid = 30210176 }}</ref><ref>{{cite journal | vauthors = Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H, Farrell B, Fernandes J, Gogichaisvili T, Golden N, Hartzenberg B, Husain M, Ulloa MI, Jerbi Z, Khamis H, Komolafe E, Laloë V, Lomas G, Ludwig S, Mazairac G, Muñoz Sanchéz M, Nasi L, Olldashi F, Plunkett P, Roberts I, Sandercock P, Shakur H, Soler C, Stocker R, Svoboda P, Trenkler S, Venkataramana NK, Wasserberg J, Yates D, Yutthakasemsunt S | display-authors = 6 | title = Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months | journal = Lancet | volume = 365 | issue = 9475 | pages = 1957–1959 | date = 2005 | pmid = 15936423 | doi = 10.1016/s0140-6736(05)66552-x | first35 = collaborators. | s2cid = 27713031 }}</ref>
===Surgery=== Surgery is required if the hematoma is greater than {{convert|3|cm|0|abbr=on}}, if there is a structural vascular lesion or lobar hemorrhage in a young patient.<ref name=emedicine/>
A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures.<ref>{{cite web | url = http://www.csmc.edu/2424.html | work = Cedars-Sinai Health System | title = Cerebral Hemorrhages | archive-url = https://web.archive.org/web/20090312064211/http://csmc.edu/2424.html | archive-date=2009-03-12 | access-date = 25 February 2009 }}</ref>
Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited.<ref name=emedicine/>
A craniectomy holds promise of reduced mortality, but the effects of long‐term neurological outcome remain controversial.<ref name="pmid31887790">{{cite journal | vauthors = Sahuquillo J, Dennis JA | title = Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 12 | article-number = CD003983 | date = December 2019 | pmid = 31887790 | pmc = 6953357 | doi = 10.1002/14651858.CD003983.pub3 }}</ref>
==Prognosis== About 8 to 33% of those with intracranial haemorrhage have neurological deterioration within the first 24 hours of hospital admission, where a large proportion of them happens within 6 to 12 hours. Rate of haematoma expansion, perihaematoma odema volume and the presence of fever can affect the chances of getting neurological complications.<ref>{{cite journal | vauthors = Lord AS, Gilmore E, Choi HA, Mayer SA | title = Time course and predictors of neurological deterioration after intracerebral hemorrhage | journal = Stroke | volume = 46 | issue = 3 | pages = 647–652 | date = March 2015 | pmid = 25657190 | pmc = 4739782 | doi = 10.1161/STROKEAHA.114.007704 }}</ref>
The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the brain stem.<ref name="Sanders and McKenna">{{cite book | vauthors = Sanders MJ, McKenna K | date = 2001 | title = Mosby's Paramedic Textbook | edition = 2nd revised | chapter = Chapter 22: Head and Facial Trauma | publisher = Mosby }}</ref> Intraparenchymal bleeds within the medulla oblongata are almost always fatal, because they cause damage to cranial nerve X, the vagus nerve, which plays an important role in blood circulation and breathing.<ref name="McCaffrey"/> This kind of hemorrhage can also occur in the cortex or subcortical areas, usually in the frontal or temporal lobes when due to head injury, and sometimes in the cerebellum.<ref name="McCaffrey"/><ref name="Graham and Gennareli ">{{cite book | vauthors = Graham DI, Gennareli TA | chapter = Chapter 5 | title = Pathology of Brain Damage After Head Injury | veditors = Cooper P, Golfinos G | date = 2000 | edition = 4th | publisher = Morgan Hill | location = New York }}</ref> Larger volumes of hematoma at hospital admission as well as greater expansion of the hematoma on subsequent evaluation (usually occurring within 6 hours of symptom onset) are associated with a worse prognosis.<ref name="NEJM Sheth" /><ref name="Stroke">{{cite journal | vauthors = Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G | title = Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality | journal = Stroke | volume = 24 | issue = 7 | pages = 987–993 | date = July 1993 | pmid = 8322400 | doi = 10.1161/01.STR.24.7.987 | s2cid = 3107793 | doi-access = free }}</ref> Perihematomal edema, or secondary edema surrounding the hematoma, is associated with secondary brain injury, worsening neurological function and is associated with poor outcomes.<ref name="NEJM Sheth" /> Intraventricular hemorrhage, or bleeding into the ventricles of the brain, which may occur in 30–50% of patients, is also associated with long-term disability and a poor prognosis.<ref name="NEJM Sheth" /> Brain herniation is associated with poor prognoses.<ref name="NEJM Sheth" />
Predicting a patient's recovery after an intracerebral hemorrhage is difficult in the first few hours. Experts warn about a phenomenon known as a "self-fulfilling prophecy": this occurs when medical care is limited because a poor prognosis is assumed, leading to a patient's death due not only to the brain injury itself, but also to the lack of active treatment. To avoid this, major guidelines recommend waiting 24 to 72 hours before making final decisions about limiting life-sustaining treatment, except in cases of catastrophic brain injury<ref>{{Cite journal |last=Steiner |first=Thorsten |last2=Purrucker |first2=Jan C |last3=Aguiar de Sousa |first3=Diana |last4=Apostolaki-Hansson |first4=Trine |last5=Beck |first5=Jürgen |last6=Christensen |first6=Hanne |last7=Cordonnier |first7=Charlotte |last8=Downer |first8=Matthew B |last9=Eilertsen |first9=Helle |last10=Gartly |first10=Rachael |last11=Gerner |first11=Stefan T |last12=Ho |first12=Leonard |last13=Holt Jahr |first13=Silje |last14=Klijn |first14=Catharina JM |last15=Martinez-Majander |first15=Nicolas |date=2025-12-01 |title=European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage |url=https://academic.oup.com/esj/article/10/4/1007/8377192 |journal=European Stroke Journal |language=en |volume=10 |issue=4 |pages=1007–1086 |doi=10.1177/23969873251340815 |issn=2396-9873 |pmc=12098356 |pmid=40401775}}</ref><ref>{{Cite web |title=American Heart Association Journals |url=https://www.ahajournals.org/action/cookieAbsent |access-date=2026-04-19 |website=American Heart Association Journals |language=en |doi=10.1161/str.0000000000000407}}</ref>. Even with these rules, data show that about 20% to 25% of patients still have their care limited very early on<ref>{{Cite journal |last=Lambea-Gil |first=Álvaro |last2=Camps-Renom |first2=Pol |last3=Martí-Fàbregas |first3=Joan |last4=Guasch-Jiménez |first4=Marina |last5=Ezcurra-Díaz |first5=Garbiñe |last6=Fernández-Vidal |first6=Joan Miquel |last7=Prats-Sanchez |first7=Luis |last8=Martínez-Domeño |first8=Alejandro |last9=de la Ossa |first9=Natalia Pérez |last10=Ramos-Pachón |first10=Anna |date=2026-04-06 |title=Early care limitation after ICH in a population-based study: what drives clinicians’ decisions? |url=https://academic.oup.com/esj/article/doi/10.1093/esj/aakag028/8607724 |journal=European Stroke Journal |language=en |volume=11 |issue=4 |doi=10.1093/esj/aakag028 |issn=2396-9873 |pmc=13058262 |pmid=41947561}}</ref>.
For spontaneous intracerebral hemorrhage seen on CT scan, the death rate (mortality) is 34–50% by 30 days after the injury,<ref name="Yadav07"/> and half of the deaths occur in the first 2 days.<ref>{{cite journal | vauthors = Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M | display-authors = 6 | title = Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group | journal = Stroke | volume = 38 | issue = 6 | pages = 2001–2023 | date = June 2007 | pmid = 17478736 | doi = 10.1161/strokeaha.107.183689 | doi-access = free }}</ref> Even though the majority of deaths occur in the first few days after ICH, survivors have a long-term excess mortality rate of 27% compared to the general population.<ref>{{cite journal | vauthors = Hansen BM, Nilsson OG, Anderson H, Norrving B, Säveland H, Lindgren A | title = Long term (13 years) prognosis after primary intracerebral haemorrhage: a prospective population based study of long term mortality, prognostic factors and causes of death | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 84 | issue = 10 | pages = 1150–1155 | date = October 2013 | pmid = 23715913 | doi = 10.1136/jnnp-2013-305200 | url = http://jnnp.bmj.com/content/early/2013/05/27/jnnp-2013-305200 | url-status = live | s2cid = 40379279 | archive-url = https://web.archive.org/web/20140222034200/http://jnnp.bmj.com/content/early/2013/05/27/jnnp-2013-305200 | archive-date = 2014-02-22 | url-access = subscription }}</ref> Of those who survive an intracerebral hemorrhage, 12–39% are independent with regard to self-care; others are disabled to varying degrees and require supportive care.<ref name="Lancet Neurology, epidemiology" />
== References == {{Reflist}} {{Commons category|Intracerebral hemorrhage}} {{Medical resources | DiseasesDB = | ICD10 = {{ICD10|I|61||i|60}}, {{ICD10|P|10|1|p|10}} | ICD9 = {{ICD9|431}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D002543 }} {{Cerebrovascular diseases}} {{Neurotrauma}} {{Authority control}}
Category:Cerebrovascular diseases Category:Intracranial hemorrhage Category:Wikipedia medicine articles ready to translate Category:Wikipedia neurology articles ready to translate Category:Types of stroke