An intracerebral hemorrhage is bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. See also: Hemorrhagic stroke

Internal bleeding can occur in any part of the brain. Blood may build up in the brain tissues, or in the space between the brain and the membranes that cover it.

The bleeding may only be in one hemisphere (lobar intracerebral hemorrhage). Or it may occur in other brain structures, such as the thalamus, basal ganglia, pons, or cerebellum (deep intracerebral hemorrhage).

An intracerebral hemorrhage can be caused by:

• Abnormalities of the blood vessels (aneurysm or vascular malformation)
• High blood pressure (hypertensive intracerebral hemorrhage)
• Protein deposits along blood vessels (amyloid angiopathy)
• Traumatic brain injury

In some cases, no cause can be found.

Blood irritates the brain tissues, causing swelling (cerebral edema). It can collect into a mass called a hematoma. Either swelling or a hematoma will increase pressure on nearby brain tissues and can quickly destroy them.

Other factors that raise the risk of intracerebral hemorrhage include the following:

• Blood and bleeding disorders
  • Decreased levels of blood platelets
  • Disseminated intravascular coagulation
  • Hemophilia
  • Leukemia
  • Sickle cell anemia
• Cerebral amyloid or brain tumors
• Liver disease (associated with increased bleeding risk in general)
• Use of aspirin or blood thinners (anticoagulant medications, such as warfarin)

Premature infants (born earlier than 35 weeks) will sometimes have bleeding into the fluid-filled spaces (ventricles) in the brain. This type of bleed is called intra-ventricular hemorrhage (IVH). This occurs in the first day or so of life and is usually not preventable.

Symptoms vary depending on the location of the bleed and the amount of brain tissue affected. The symptoms usually develop suddenly, without warning, often during activity. They may occasionally develop in a stepwise pattern, or they may get worse over time.

Symptoms include:

• Abnormal sense of taste
• Change in alertness (level of consciousness)
  • Apathetic, withdrawn
  • Sleepy, lethargic, stuporous
  • Unconscious, comatose
• Difficulty speaking or understanding speech
• Difficulty swallowing
• Difficulty writing or reading
• Headache
  • May occur when lying flat
  • May awaken patient from sleep
  • May increase with change in position
  • May increase with bending, straining, and coughing
• Loss of coordination
• Loss of balance
• Movement changes
  • Difficulty moving any body part
  • Hand tremor
  • Loss of fine motor skills
  • Weakness of any body part
• Nausea, vomiting
• Seizure
• Sensation changes
  • Abnormal sensations
  • Decreased sensation
  • Facial paralysis
  • Numbness or tingling
• Vision changes
  • Any change in vision
  • Decreased vision, loss of all or part of vision
  • Double vision
  • Eyelid drooping
  • Pupils different size
  • Uncontrollable eye movements

A medical history and brain/nervous system (neurological) exam may find evidence of increased intracranial pressure or decreased brain functions. Your specific symptoms can help the health care provider tell which part of the brain is affected.

Other signs include:

• Abnormal reflexes
• Changes in eye movement
• Decreased vision
• Inability to feel sensations properly
• Loss of movement or coordination
• Swelling of the optic nerve from increased pressure in the brain

Tests may include:

• Bleeding time
• Cerebral angiography or spiral CT scan angiography of the head
• Complete blood count (CBC)
• Head CT scan
• Head MRI or MRA
• Kidney function tests
• Liver function tests
• Platelet count
• Prothrombin time ( PT) or partial thromboplastin time ( PTT)

An intracerebral hemorrhage is a severe condition requiring prompt medical attention. It may develop quickly into a life-threatening situation.

Treatment depends on the location, cause, and amount of the hemorrhage.

Surgery may be needed, especially if there is bleeding in the cerebellum. Surgery may also be done to repair or remove structures causing the bleed (such as a cerebral aneurysm or arteriovenous malformation).

Medicines used may include:

• Anticonvulsants to control seizures
• Corticosteroids or diuretics to reduce swelling
• Painkillers

You may need blood, blood products, or fluids given through a vein (IV) to make up for loss of blood and fluids. Other treatments may be recommended, depending on your condition and symptoms.

How well a patient does depends on the size of the hematoma and the amount of swelling.

There may be a complete recovery, or some permanent loss of brain function. Death is possible and may occur quickly despite prompt medical treatment. Recovery depends on the amount of blood that bleeds into the brain, and the area where the bleeding occurs.

Medications, surgery, or other treatments may have severe side effects.

• Hemorrhagic stroke
• Permanent loss of any brain function
• Side effects of medications used to treat the disorder

Go to the emergency room or call 911 if there are symptoms of intracerebral hemorrhage. This is a life-threatening condition.

Emergency symptoms include:

• Difficulty breathing
• Inability to speak or swallow
• Loss of consciousness
• Paralysis of an arm, leg, or half of the body
• Seizures

Treating and controlling underlying disorders may reduce the risk of developing intracerebral hemorrhage. Get high blood pressure treated. Do not stop taking medications unless told to do so by your doctor.

Conditions such as an aneurysm can often be treated before they cause bleeding in the brain.

Zivin JA. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 432.

Goldstein LB. Prevention and management of stroke. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier;2007: chap 58.