Definition

An intracerebral hemorrhage (ICH) is bleeding in the brain tissue caused by the rupture of a blood vessel within the head.


CT scan of intracerebral hemorrhage

Causes

  • High blood pressure: chronic arterial hypertension
  • Abnormalities of the blood vessels: arteriovenous malformations, amyloid angiopathy etc.
  • Hemorrhage into a stroke
  • Certain tumors
  • Bleeding disorders (i.e. patients with hereditary bleeding abnormalities or patients on blood thinners)
  • Traumatic brain injury
  • Drug abuse (cocaine, alcohol, methamphetamines etc.)

Risks

Risk factors are things associated with an increased chance of developing a disease or condition.

  • Bleeding disorders
  • Use of blood thinners or aspirin
  • Brain tumors
  • Liver disease
  • Previous stroke
  • Seizures

Symptoms

ICH can manifest with a wide spectrum of symptoms depending on the location of the bleed and the size of the hematoma. Most ICH develop suddenly. Less frequently they develop in a stepwise, episodic manner, or they may get progressively worse.

  • Abrupt onset of headache
  • Increased intracranial pressure
  • Nausea
  • Vomiting
  • Difficulty swallowing
  • Difficulty speaking
  • Dizziness
  • Changes in vision
  • Abnormal reflexes
  • Inability to feel sensations properly
  • Lack of balance
  • Loss of coordination
  • Confusion
  • Seizure
  • Decreased level of consciousness
  • Stupor
  • Coma

Diagnosis

  • Thorough history and physical examination
  • Baseline laboratory studies
  • CT scan of the brain
  • Head MRI scan
  • Cerebal angiography if indicated

Treatment

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

  • Medication to control blood pressure, reduce swelling and control seizures
  • Reduction of intracranial pressure
  • Surgery

Prevention

  • Treatment and control of underlying disorders may reduce the risk of developing intracerebral hemorrhage.
  • Treat high blood pressure
  • Don't smoke
  • Don't abuse drugs
  • Avoid head injury by common sense measures—wearing a seat belt, wearing a helmet for appropriate activies, driving only when sober, applying safety measures in the home, such as using non-skid pad under carpets.
  • Conditions such as a vascular malformation can often be treated before they cause bleeding in the brain.

Case Study

A 64 year old female presented to the Mount Sinai emergency room after suddenly stumbling at home and becoming unable to move the right side of her body and face. A diagnostic CT of the head was ordered and she was found to have a left basal ganglia hemorrhage causing pressure on the brain and a decreased level of consciousness. Her family agreed to enroll her in the MISTIE (Minimally Invasive Surgery Plus rt-PA for ICH Evacuation) trial. Along with standard medical care, a small catheter was inserted by Dr. Joshua B. Bederson into the center of the clot, some of the clot was aspirated and she received several doses of a clot dissolving drug, rt-PA.

After a week on the neurosurgery service she was transferred to the MSMC acute rehabilitation service. Despite the need for another surgery for an unrelated condition, the patient did well and was discharged to home about ten weeks after the bleed. She continued to improve and at the three month follow up was walking several blocks without assistance and her speech had improved. At the 180 day assessment it was found that her recovery had slowed since she had not followed up with outpatient rehabilitation and the appropriate referrals were made.

If you want to learn more about Intracerebral Hemorrhage call the Mount Sinai Department of Neurosurgery at 212-241-2377.

Image used with permission from Joshua B. Bederson, MD