Intracerebral Hemorrhage

What is Intracerebral Hemorrhage?

Intracerebral hemorrhage (ICH) is a type of stroke that happens when a blood clot forms inside the brain tissue, sometimes extending into the fluid-filled spaces of the brain, known as ventricles. This condition, which accounts for about 10-15% of all strokes, can be very severe and may lead to significant disability or death.

Several factors can increase the risk of developing ICH. These include long-term high blood pressure, a condition called amyloid angiopathy (where abnormal protein deposit damages the walls of the brain’s blood vessels), taking blood-thinning medications, and having abnormal blood vessels in the brain. The resulting injury to the brain is often categorized as primary and secondary. Primary damage refers to the initial harm to the brain caused by the blood clot, while secondary damage refers to the harm caused by complications from the blood accumulation inside the brain.

Treatment for ICH can vary, ranging from medications to open surgery to actively remove the blood clot. Research is still ongoing to find less invasive treatments to improve the chances of recovery for individuals with this condition.

What Causes Intracerebral Hemorrhage?

Non-traumatic brain bleeds, also known as Intracerebral hemorrhage (ICH), can be broken down into two types: primary and secondary. Primary bleeds make up for about 85% of all ICH cases and are usually due to long-term high blood pressure or a condition called amyloid angiopathy, which involves abnormal protein buildup in the brain’s blood vessels. Secondary brain bleeds refer to those that are connected to other issues like bleeding disorders (which could be drug-induced, inherited, or developed over time), abnormalities in the blood vessels, tumors, a stroke that has turned into a bleed, or drug misuse.

Primary or spontaneous ICH accounts for over 85% of bleeding strokes. It’s typically diagnosed when no other possible cause is found and is commonly associated with a past history of chronic high blood pressure, advancing age, and the location of the blood clot. In patients with long-term high blood pressure, it’s believed that changes in the small arteries feeding deep parts of the brain can lead to what’s called Charcot-Bouchard aneurysms. More than 60% of primary brain bleeds are connected to high blood pressure, and these bleeds are most often seen in areas in the back and base of the brain, and thalamus. Brain hemorrhages in older individuals can often signal amyloid angiopathy. This is a disease leading to excessive protein buildup within blood vessel walls.

On the other hand, if a brain bleed occurs due to an underlying structural problem, like blood vessel anomalies or cancerous tissue, it’s categorized as secondary ICH. Vascular abnormalities include formations where arteries and veins are connected abnormally, malformed blood vessels, brain aneurysms, and abnormal connections between arteries and veins. These are usually the cause of ICH in the young and otherwise healthy individuals. Bleeding in the brain can also be secondary to a tumor or a stroke that has turned into a bleed. Additionally, inherited and acquired bleeding disorders are common causes of ICH, with their prevalence increasing due to the large number of adults on blood thinners and antiplatelet medications (like aspirin).

Research has shown certain trends in the population susceptible to brain bleeds, proposing both alterable and non-alterable risk factors. The non-alterable factors include being non-white, older, having familial apolipoprotein syndromes, and being male. The presence of cerebral amyloid angiopathy also ups the risk of both localized and recurrent brain bleeds. Uncontrolled or untreated high blood pressure doubles the risk of ICH in aging people. Other alterable risk factors include drug and alcohol misuse, including nicotine and cocaine.

Risk Factors and Frequency for Intracerebral Hemorrhage

Strokes, which can be either ischemic or hemorrhagic, have a significant global impact. In 2010, approximately 33 million people worldwide had a stroke. Hemorrhagic strokes constituted about one-third of these cases and resulted in over half of the deaths. While globally, nearly 20 out of every 100,000 people experience a stroke annually, rates are double in regions with lower or middle incomes compared to wealthier nations. A potential explanation for this increased risk could be less education about stroke prevention and limited access to healthcare. The good news is that deaths from strokes are decreasing worldwide.

• Strokes are a major health issue globally.
• In 2010, around 33 million people worldwide had a stroke.
• Hemorrhagic strokes account for about one-third of all cases and over half of all stroke-related deaths.
• Annually, nearly 20 out of every 100,000 people have a stroke.
• The occurrence rate of strokes is twice as high in low/middle-income regions compared to wealthier countries.
• Mortality from strokes is declining worldwide.

In the United States, strokes rank fourth on the list of leading causes of death, with hemorrhagic strokes accounting for just under 20% of all strokes. When it comes to the people most affected by strokes, the elderly (those aged 55 and older), males, and individuals of African and Asian descent are more frequently diagnosed. Within the Japanese population, the incidence is even higher, with 55 out of every 100,000 people having a hemorrhagic stroke. This might be due to the higher rates of alcohol use and hypertension among this group.

• Strokes are the fourth leading cause of death in the United States.
• Just under 20% of all stroke incidents in the U.S. are hemorrhagic strokes.
• Stroke is diagnosed more often in people over 55, males, and individuals of African and Asian descent.
• In Japan, 55 out of every 100,000 people have a hemorrhagic stroke, potentially due to high rates of alcohol use and hypertension.

Signs and Symptoms of Intracerebral Hemorrhage

When someone shows signs of an intracerebral hemorrhage (ICH) – a type of stroke caused by bleeding within the brain – doctors need to learn about their medical history and symptoms. Important information includes how quickly symptoms developed and whether they started suddenly during physical activity or after using recreational substances such as drugs or alcohol. If the person is a smoker, this can also be relevant as it can contribute to blood vessel conditions that increase the risk of ICH.

The main sign of ICH is generally a sudden decrease in brain function like weakness on one side of the body or changes in vision, dependent on where the bleed happens in the brain. This is typically associated with becoming less responsive or conscious, which is evaluated using the Glasgow coma scale. Other common symptoms include:

• Headache
• Nausea or vomiting
• Seizures
• High diastolic blood pressure (above 110 mmHg)

When the bleeding extends into the chambers in the brain that hold cerebrospinal fluid (the ventricles), it can cause increased pressure in the brain. This condition, known as obstructive hydrocephalus, is accompanied by other symptoms such as:

• Headaches that worsen when lying flat
• Swelling of the optic disc (papilledema)
• Nausea or vomiting
• Double vision (diplopia)
• Confusion
• Decreased sleeping patterns

The initial care for these patients includes making sure their airway is open and they are breathing properly, followed by checking their blood circulation. It’s important to maintain a specific blood pressure to ensure adequate blood flow to the brain. If their conscious state is extremely low (as measured by the Glasgow coma scale), they may need help with breathing. Doctors will also look for any obvious outward signs, such as checking whether their pupils are equal and responsive – an important sign of severe brain injury that requires immediate attention.

Finally, it’s crucial to investigate whether the patient is taking any significant blood-thinning medications or has any conditions that affect their body’s clotting ability, which can be checked using routine blood tests. If there are any problems with blood clotting, appropriate measures can be taken to correct them.

Testing for Intracerebral Hemorrhage

When a doctor suspects that a patient has intracerebral hemorrhage (ICH), which is a type of stroke caused by bleeding within the brain, they often recommend a quick and easily accessible imaging test known as a non-contrast CT scan of the head. This form of imaging, often considered a “gold-standard,” can differentiate between various brain abnormalities, such as different types of strokes and distinguish hemorrhages from other conditions. It also helps to reveal the size of the hemorrhage and its effects, such as swelling and pressure increase inside the brain.

MRI scans can also help detect ICH and can help identify older clots, but they have two main downsides – they take more time and may not be readily available in some hospitals.

On a CT scan, an acute ICH is observed as a denser area within the brain tissue, surrounded by a less dense area which signifies swelling around blood vessels. To estimate the clot’s size, doctors take the measurements of the clot’s depth, height, and length and perform a specific calculation.

Due to the risk of the hemorrhage expanding or further bleeding, which affects up to 38% of ICH patients, a doctor might also use other imaging tests like a CT scan with contrast or a CT Angiography (CTA). These imaging tests aim to identify any abnormal blood vessels that might have caused the hemorrhage. This is especially important before any emergency procedures to remove the clot, as surgeons usually prefer to attend to vascular malformations in a planned context.

When the CT scan with contrast, also called a contrast CT scan, highlights a densely-packed area within the hemorrhage, it can suggest active bleeding. This is often referred to as the ‘spot sign.’ If there are more of these densely-packed areas, it may mean that there is an increased chance of the clot enlarging.

In younger patients with risk factors, there might be vascular lesions causing the ICH. Indications of these in scans might include the presence of SAH (subarachnoid hemorrhage), clot shape, and its proximity to major blood vessels. Apart from CTA, MRI scans specialized in imaging blood vessels (MR angiography and MR venography) can detect vascular abnormalities, like arteriovenous malformations and cavernomas. An interventional intracranial catheter angiogram is usually performed to verify the diagnosis of a vascular malformation, as it offers more detailed information regarding the active phases of blood filling and emptying in veins and arteries.

Treatment Options for Intracerebral Hemorrhage

When a person is suspected to have a stroke, the primary focus is to ensure they can breathe normally and their heart is beating properly, and to get them to the nearest hospital equipped to handle stroke emergencies. Clinicians may seek information from any witnesses to understand more about the patient’s condition, medical history, and any medications they are on.

Upon reaching the hospital, the healthcare team will promptly attempt to minimize the risk of further internal bleeding and clot growth within the first day to three days. The team will strive to correct any abnormalities in the patient’s blood clotting process. This might include treating deficiencies in specific clotting factors and countering the effects of any blood-thinning medications the patient is taking. In patients taking anticoagulants, treatments could involve the use of fresh frozen plasma, vitamin K, prothrombin complex concentrates, and new medications like recombinant activated factor VIIa. The use of platelet transfusions in those affected by antiplatelet medication is still being studied.

Many people experience high blood pressure when they’re having a stroke due to various reasons, including pain, stress, a history of hypertension, and raised intracranial pressure (ICP), which is the pressure inside the skull. High blood pressure might cause the blood clot to grow, so the medical team will focus on lowering it. However, significant drops in blood pressure might be harmful to some patients, particularly those who usually have high blood pressure. Therefore, the reduction should be done carefully under close monitoring.

Elevated or reduced blood glucose (blood sugar) levels can be harmful, so the team also strives to maintain normal glucose levels while strictly avoiding low levels. If the patient has experienced seizures, they could be administered antiseizure medication; however, routine use of these drugs does not appear to decrease the rate of stroke-related epilepsy.

The team also aims to prevent additional brain damage by ensuring that the amount of blood reaching the brain (cerebral perfusion pressure or CPP) stays above a certain level. To reduce intracranial pressure, simple measures would be taken like elevating the patient’s head at a 30-degree angle and giving appropriate pain relievers.

One of the urgent complications of a stroke can be hydrocephalus, a buildup of fluid in the brain. This may quickly happen in specific types of stroke due to the anatomical structure of the brain. The primary treatment in these cases is an external ventricular drain (EVD), a device to aid in reducing pressure in the brain.

In some cases, surgically removing the blood clot could improve outcomes, especially in patients that are good surgical candidates, have large clots causing brainstem compression, decreased consciousness, and/or hydrocephalus.

Lastly, the benefits of surgery versus medical management are still being debated. Large studies like the STITCH trials concluded that there was no significant benefit from surgery. However, it was noted that a much smaller group of patients had more encouraging results from surgery compared to medical management. Even then, surgery typically serves as a life-saving instance for patients showing clinical deterioration.

Emerging research is also exploring minimally invasive techniques for treating strokes, which can reduce brain trauma and shorten surgery times. These involve using advanced guidance systems to insert a catheter into the clot to deliver clot-dissolving medications or aspirate the clot if necessary.

What else can Intracerebral Hemorrhage be?

Many health conditions can show up suddenly with symptoms that mimic an acute Intracerebral Hemorrhage (ICH), which is a type of stroke caused by bleeding in the brain. Common symptoms like headaches and nausea, along with confusion, seizures, and physical signs of brain damage can show up in different types of brain bleeding. These include:

• Subarachnoid hemorrhage (SAH)
• Acute subdural hemorrhage
• Chronic subdural hemorrhage

SAH often starts with a sudden severe headache, like getting hit in the back of the head. But apart from this unique symptom, patients might show up in the same way as those with acute ICH. On the other hand, an acute subdural hemorrhage might have the same symptoms but the key difference is that it usually occurs right after an injury. Chronic subdural hemorrhages, which frequently happen in older individuals, particularly those on blood-thinning medication, often follow a pattern of frequent falls, lasting headaches, confusion, or brain damage signs. Brain scans can help differentiate these three conditions.

Brain tumors usually develop slowly. Because they grow gradually, most people can manage symptoms until pressure inside the skull builds up enough to cause headaches, nausea, vomiting, seizures, and lowered consciousness. A key indicator of brain tumors is a subtle history of progressing symptoms, and usually, a special type of computerized tomography (CT) imaging scan is needed for diagnosis. In some cases, the brain tumors might have bleeding, which could cause confusion in diagnosis. A later magnetic resonance imaging (MRI) scan might be needed for a more accurate diagnosis.

Lastly, serious infections like subdural empyema and abscesses can also mimic acute ICH. However, these patients commonly have a recent history of infections in the face or head regimes (like the ear or sinuses) and/or general symptoms of fever or shaking chills. Again, advanced brain scan techniques like CT and MRI can help distinguish between these conditions.

What to expect with Intracerebral Hemorrhage

Acute Intracerebral Hemorrhage (ICH), a type of stroke caused by bleeding within the brain, can be a severe event. The death rate from this condition can be influenced by the size of the internal bleeding, its location in the brain, and the patient’s Glasgow Coma Scale (GCS) score, which measures a patient’s level of consciousness, when admitted to the hospital. The death rate within the first 30 days can be as high as 50%, with most fatalities occurring within 24 hours of the onset of symptoms. The presence of additional blood in the ventricles (fluid-filled structures in the brain) and increased fluid pressure within the brain (hydrocephalus) can worsen the patient’s condition significantly.

In severe cases, if a patient arrives at the hospital with a GCS score of less than 9 and a blood clot size of 60 ml or more, the mortality rate could be nearly 90%. Bleeding in the lower part of the brain (posterior fossa) and brainstem is associated with a worse outlook because of the potential development of obstructive hydrocephalus and the fact that these areas control life-sustaining functions. Only about 20% of patients who survive are able to live independently six months after the brain bleed. Other influencing factors on patient outcomes after an ICH include the patient’s age and any other pre-existing health conditions (comorbidities).

While it is hard to strictly predict the outcomes for these patients, it’s key to avoid making hasty decisions about ending a patient’s care. Doing so can lead to a phenomenon known as a self-fulfilling prophecy, meaning the expectations can influence the outcome. Therefore, comprehensive medical care and treatment should be offered to all acute ICH patients, unless they have a previously documented advance directive or expressed wishes against it, for at least the first 24 to 48 hours after the onset of the stroke.

Possible Complications When Diagnosed with Intracerebral Hemorrhage

Around 30% to 50% of patients with a bleeding inside the skull can extend the blood clot into the aqueducts of the brain, something that happens frequently in a specific type of brain bleeding. This condition can lead to worst outcomes because it can harm the brain tissue, lead to inflammation, and cause a type of fluid accumulation in the brain and its complications.

This specific type of fluid accumulation in the brain is a problem that can appear from this condition and can cause dangerous complications due to raised pressure inside the skull. It tends to happen more often in patients with larger blood volume in the brain aqueducts. In some cases, these brain aqueducts can get partially blocked by the products of the blood clot, leading to another type of fluid accumulation in the brain, which again can cause significant harm to the patient.

Seizures often appear as one of the first symptoms of this type of brain bleeding but can sometimes occur as delay complications. Nearly 70% of seizures happen within the first day of the bleeding, and most (90%) occur within the first three days. Seizures that happen within the first two hours of the brain bleed are due to changes in the brain tissues and malfunctioning biochemistry. In contrast, delay seizures are more likely to occur because of scar tissue. Non-convulsive seizures are also common in patients with this condition and are usually considered when someone suddenly scores low on a brain function tests and if a clot is found in parts of the brain prone to seizures. Delayed seizures are often seen in patients with increased brain swelling.

A clot in the bloodstream that travels (VTE), which forms deep vein clots (DVT) or blood clots in the lung (PE), is a frequent complication in patients admitted to the hospital. It has a rate of about 3% to 7% in patients with this type of brain bleeding. Symptomatic DVTs are less common though the rates of silent DVTs are described as being up to 17%. Patients with this condition are more likely to develop this complication due to their lack of mobility, usually resulting from paralysis. Other factors that increase the risk for this complication are the advanced age of patients, discontinuation of anticoagulant drugs, the struggle to start preventive anticoagulation, and a high clot formation activity after the brain bleed.

Approximately 60% of patients with this type of brain bleeding experience temporary high blood glucose levels as part of the body’s stress response. The increase in blood glucose levels is linked to the size of the blood clot, the expansion of the clot, and the swelling around it, making high blood glucose levels a predictive factor of worse outcomes.

During the crucial period following this type of brain bleed, over 70% of patients display high blood pressure even if they had no history of it before admission. The reason behind this is not fully understood, but it may be caused by the activation of the brain’s stress response due to raised pressure inside the skull. This high blood pressure following the brain bleed is connected to high bleeding recurrence rates, clots enlargement, and therefore, worse outcomes. However, the impact of blood pressure levels on mortality follows a U-distribution because low blood pressure acts as a bad prognostic factor due to reduced blood supply to the brain and resulting brain oxygen deficiency.

Preventing Intracerebral Hemorrhage

In recent years, more people are becoming aware of the signs and symptoms of a stroke thanks to the campaigning of the acronym ‘FAST’ which stands for Facial weakness, Arm weakness, Speech problems, and Time to call for help. This has enabled more people to spot these warning signs in their loved ones. It is important to get immediate medical help if someone exhibits these symptoms to improve their survival chances and minimize health complications.

There are certain factors which can increase the risk of a stroke that can be managed or reversed if a person is aware of them. For example, individuals with high blood pressure should understand the need to keep their blood pressure in check. Those who smoke or consume excessive amounts of alcohol should know they are at a higher risk for blood vessel damage that can lead to stroke. Nowadays, there are more people taking medication that affects blood clotting (anticoagulants and antiplatelet). Those, for instance, on a medication called Warfarin, which effect can be measured with regular blood testing, should have their blood checked frequently. This is necessary because managing what’s called INR (a measure of how long it takes blood to clot) reduces the risk of unwanted bleeding.

After a stroke, it’s important that patients and loved ones understand that the after-effects can be quite serious, possibly leading to long-term dependence. For patients who have had brain surgeries or have experienced seizures, there are certain restrictions applied to their ability to drive. These restrictions depend on their unique health circumstances and laws of their respective residential area.