Cerebral hemorrhage

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Cerebral hemorrhage
intracerebral hemorrhage (ICH), cerebral hematoma, cerebral bleed
Intracerebral hemorrage (CT scan).jpg
CT scan of a spontaneous intracranial hemorrhage, leaking into the lateral ventricles
Classification and external resources
Specialty Neurosurgery
ICD-10 I61, P10.1
ICD-9-CM 431
MeSH D002543

A cerebral hemorrhage (also spelled haemorrhage) is a type of intracranial hemorrhage that occurs within the brain tissue. It can be caused by brain trauma, or it can occur spontaneously in hemorrhagic stroke. Non-traumatic intracerebral hemorrhage (or hemorrhagic stroke) is a spontaneous bleeding into the brain tissue because of rupture of blood vessels that may be caused by high blood pressure, amyloidosis, or structural weakness of blood vessel walls (aneurysms, arterio-venous malformations).[1]

A cerebral hemorrhage is an intra-axial hemorrhage; that is, it occurs within, rather than outside, the brain tissue. The other category of intracranial hemorrhage is extra-axial hemorrhage, such as epidural, subdural, and subarachnoid hematomas, which all occur within the skull but outside of the brain tissue. There are two main kinds of intra-axial hemorrhages: intraparenchymal hemorrhage and intraventricular hemorrhages. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious medical emergency because they can increase intracranial pressure, which if left untreated can lead to coma and death. The mortality rate for intraparenchymal bleeds is over 40%.[2]

Signs and symptoms[edit]

Patients with intraparenchymal bleeds have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed.[3] Other symptoms include those that indicate a rise in intracranial pressure caused by a large mass putting pressure on the brain.[3] Intracerebral hemorrhages are often misdiagnosed as subarachnoid hemorrhages due to the similarity in symptoms and signs. A severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage. Another common symptom is a patient can collapse. Some people may experience continuous bleeding from the ear. Some patients may also go into a coma before the bleed is noticed.


Splenial Infarct / Boomerang Sign, Sturge Weber Syndrome / Vein of Galen Malformation
Axial CT scan showing hemorrhage in the posterior fossa[4]

Intracerebral bleeds are the second most common cause of stroke, accounting for 10% of hospital admissions for stroke.[5] High blood pressure raises the risks of spontaneous intracerebral hemorrhage by two to six times.[4] 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,[6][7][8] rupture of an aneurysm or arteriovenous malformation (AVM), and bleeding within a tumor are additional causes. Amyloid angiopathy is a not uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis. Infection with the k serotype of Streptococcus mutans may also be a risk factor, because of its prevalence in stroke patients and production of collagen-binding protein.[9]

Risk factors for ICH include:[10]

Tramautic 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.


Spontaneous ICH with hydrocephalus on CT scan[4]

Both computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been proved to be effective in diagnosing intracranial vascular malformations after ICH.[11] So frequently, a CT angiogram will be performed in order to exclude a secondary cause of hemorrhage[12] 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.[12]


Treatment depends substantially of the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.



Surgery is required if the hematoma is greater than 3 cm (1 in), if there is a structural vascular lesion or lobar hemorrhage in a young patient.[16]

Other treatment[edit]


The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the brain stem.[2] 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.[6] 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.[6][21]

For spontaneous ICH seen on CT scan, the death rate (mortality) is 34–50% by 30 days after the insult,[4] and half of the deaths occur in the first 2 days.[22] Even though the majority of deaths occurs in the first days after ICH, survivors have a long term excess mortality of 27% compared to the general population.[23]

The inflammatory response triggered by stroke has been viewed as harmful in the early stage, focusing on blood-borne leukocytes, neutrophils and macrophages, and resident microglia and astrocytes.[24] A human postmortem study shows that inflammation occurs early and persists for several days after ICH.[25] New area of interest are the Mast Cells.[26]


It accounts for 20% of all cases of cerebrovascular disease in the US, behind cerebral thrombosis (40%) and cerebral embolism (30%).[27]

It is two or more times more common in black than white people.[28]


  1. ^ Hemphill, J. Claude; Greenberg, Steven M.; Anderson, Craig S.; Becker, Kyra; Bendok, Bernard R.; Cushman, Mary; Fung, Gordon L.; Goldstein, Joshua N.; Macdonald, R. Loch (2015-07-01). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (7): 2032–2060. doi:10.1161/STR.0000000000000069. ISSN 0039-2499. PMID 26022637. 
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  11. ^ Josephson, Colin B; White, Philip M; Krishan, Ashma; Al-Shahi Salman, Rustum (1 September 2014). "Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage". The Cochrane Library. 9: CD009372. doi:10.1002/14651858.CD009372.pub2. PMID 25177839. Retrieved 16 September 2014. 
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  13. ^ Tsivgoulis, G; Katsanos, AH; Butcher, KS; Boviatsis, E; Triantafyllou, N; Rizos, I; Alexandrov, AV (21 October 2014). "Intensive blood pressure reduction in acute intracerebral hemorrhage: A meta-analysis.". Neurology. 83 (17): 1523–9. doi:10.1212/wnl.0000000000000917. PMID 25239836. 
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  21. ^ Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" Cooper P and Golfinos G. 2000. Head Injury, 4th Ed. Morgan Hill, New York.
  22. ^ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults
  23. ^ Hansen, B.M.; Nilsson O.G.; Anderson H; et al. (Oct 2013). "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 of Neurology, Neurosurgery & Psychiatry. 84 (10): 1150–1155. doi:10.1136/jnnp-2013-305200. 
  24. ^ Wang J (December 2010). "Preclinical and clinical research on inflammation after intracerebral hemorrhage". Prog. Neurobiol. 92 (4): 463–77. doi:10.1016/j.pneurobio.2010.08.001. PMC 2991407free to read. PMID 20713126. 
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  26. ^ [1] Lindsberg e.a.: Mast cells as early responders in the regulation of acute blood–brain barrier changes after cerebral ischemia and hemorrhage
  27. ^ Page 117 in: Henry S. Schutta; Lechtenberg, Richard (1998). Neurology practice guidelines. New York: M. Dekker. ISBN 0-8247-0104-6. 
  28. ^ Copenhaver BR, Hsia AW, Merino JG, et al. (October 2008). "Racial differences in microbleed prevalence in primary intracerebral hemorrhage". Neurology. 71 (15): 1176–82. doi:10.1212/01.wnl.0000327524.16575.ca. PMC 2676986free to read. PMID 18838665. 

Further reading[edit]

  • Hemphill JC, 3rd; Greenberg, SM; Anderson, CS; Becker, K; Bendok, BR; Cushman, M; Fung, GL; Goldstein, JN; Macdonald, RL; Mitchell, PH; Scott, PA; Selim, MH; Woo, D (28 May 2015). "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.". Stroke; a journal of cerebral circulation. 46: 2032–60. doi:10.1161/STR.0000000000000069. PMID 26022637. 

External links[edit]