intracerebral hemorrhage (ICH)
Intracerebral hemorrhage (ICH)
is a type of stroke caused by bleeding within
the brain tissue itself a very life-threatening
situation. A stroke occurs when the brain is
deprived of oxygen due to an interruption of
its blood supply. ICH is most commonly caused
by hypertension, arteriovenous malformations,
or head trauma. Treatment focuses on stopping
the bleeding, removing the blood clot (hematoma),
and relieving the pressure on the brain.
What is an intracerebral hemorrhage (ICH)?
Tiny arteries bring blood to areas
deep inside the brain (see Anatomy of the Brain).
High blood pressure (hypertension) can cause
these thin-walled arteries to rupture, releasing
blood into the brain tissue. The blood collects
and forms a clot, called a hematoma, which grows
and causes pressure on surrounding brain tissue
(Fig. 1). Increased intracranial pressure (ICP)
makes a person confused and lethargic. As blood
spills into the brain, the area that artery
supplied is now deprived of oxygen-rich blood
called a stroke.
As blood cells within the clot die, toxins are
released that further damage brain cells in
the area surrounding the hematoma.
An intracerebral hemorrhage (ICH) is usually
caused by rupture of tiny arteries within the
brain tissue (left). As blood collects, a hematoma
or blood clot forms causing increased pressure
on the brain. Arteriovenous malformations (AVMs)
and tumors can also cause bleeding into brain
An ICH can occur close to the
surface or in deep areas of the brain. Sometimes
deep hemorrhages can expand into the ventricles
the fluid filled spaces in the center
of the brain.
are the symptoms?
If you experience the symptoms
of an ICH, call 911 immediately! Symptoms usually
come on suddenly and can vary depending on the
location of the bleed. Common symptoms include:
- headache, nausea, and vomiting
- lethargy or confusion
- sudden weakness or numbness of the face,
arm or leg, usually on one side
- loss of consciousness
- temporary loss of vision
- Hypertension: an elevation
of blood pressure that may cause tiny arteries
to burst inside the brain.
- Blood thinner therapy:
drugs such as coumadin, heparin, and warfarin
used to treat heart and stroke conditions.
- AVM: a
tangle of abnormal arteries and veins with
no capillaries in between.
a bulge or weakening of an arterial wall.
- Head trauma: fractures to the skull
and penetrating wounds (gunshot) can damage
an artery and cause bleeding.
- Bleeding disorders: hemophilia,
sickle cell anemia, DIC, thrombocytopenia.
- Tumors: highly vascular tumors such
as angiomas and metastatic tumors can bleed
into the brain tissue.
- Amyloid angiopathy: a degenerative
disease of the arteries.
- Drug usage: cocaine and other illicit
drugs can cause ICH.
- Spontaneous: ICH by unknown causes.
Who is affected?
Ten percent of strokes are caused
by ICH (approximately 70,000 new cases each
year). ICH is twice as common as subarachnoid
hemorrhage (SAH) and has a 40% risk of death.
ICH occurs slightly more frequently among men
than women and is more common among young and
middle-aged African Americans and Japanese.
Advancing age and hypertension are the most
important risk factors for ICH. Approximately
70% of patients experience long-term deficits
after an ICH.
How is a diagnosis made?
When you or a loved one is brought
to the emergency room with an ICH, the doctor
will learn as much about your symptoms, current
and previous medical problems, current medications,
family history, and perform a physical exam.
Diagnostic tests help doctors determine the
source and location of the bleeding.
Computed Tomography Angiography (CTA) scan is a noninvasive X-ray to review the
anatomical structures within the brain to see
if there is any blood in the brain (Fig. 2).
A newer technology called CT angiography involves
the injection of contrast into the blood stream
to view arteries of the brain.
2. CT scan showing a large ICH.
Angiogram is an invasive procedure,
where a catheter is inserted into an artery
and passed through the blood vessels to the
brain. Once the catheter is in place, a contrast
dye is injected into the bloodstream and X-ray
images are taken.
Magnetic resonance imaging (MRI) scan is a noninvasive test, which uses
a magnetic field and radio-frequency waves to
give a detailed view of the soft tissues of
your brain. An MRA (Magnetic Resonance Angiogram)
is the same non-invasive study, except it is
also an angiogram, which means it examines the
blood vessels as well as the structures of the
What treatments are available?
Once the cause and location of
the bleeding is identified, medical or surgical
treatment is performed to stop the bleeding,
remove the clot, and relieve the pressure on
the brain. If left alone the brain will eventually
absorb the clot within a couple of weeks
however the damage to the brain caused by ICP
and blood toxins may be irreversible.
Generally, patients with small
hemorrhages (<10 cm3) and minimal deficits
are treated medically. Patients with cerebellar
hemorrhages (>3 cm3) who are deteriorating
or who have brainstem compression and hydrocephalus
are treated surgically to remove the hematoma
as soon as possible. Patients with large lobar
hemorrhages (50 cm3) who are deteriorating usually
undergo surgical removal of the hematoma.
Blood pressure is managed to decrease the risk
of more bleeding yet provide enough blood flow
(perfusion) to the brain.
Controlling intracranial pressure
is the biggest factor in the outcome of ICH.
A device called an ICP monitor is placed directly
into the ventricles or within the brain to measure
pressure. Normal ICP is 20mm HG.
Removing cerebrospinal fluid (CSF)
from the ventricles is a common method to control
ICP. A ventricular catheter (VP shunt) may be
placed in the ventricles to drain CSF fluid
to allow room for the hematoma to expand without
damaging the brain. Hyperventilation also helps
control ICP. In some cases, coma may be induced
with drugs to bring down ICP.
The goal of surgery is to remove as much of
the blood clot as possible and stop the source
of bleeding if it is from an identifiable cause
such as an AVM or tumor. Depending on the location
of the clot either a craniotomy or a stereotactic
aspiration may be performed.
- Craniotomy involves cutting a hole in the skull with a
drill to expose the brain and remove the clot.
Because of the increased risk to the brain,
this technique is usually used only when the
hematoma is close to the surface of the brain
or if it is associated with an AVM or tumor
that must also be removed.
- Stereotactic aspiration is a less invasive technique preferred for large
hematomas located deep inside the brain. The
procedure requires attaching a stereotactic
frame to your head with four pins (screws).
The pin site areas are injected with local anesthesia
to minimize discomfort. A metal cage, which
looks like a birdcage, is placed on the frame.
Next, you undergo a CT scan to help the surgeon
pinpoint the exact coordinates of the hematoma.
In the OR, the surgeon drills a small hole about
the size of quarter in the skull. With the aid
of the stereotactic frame, a hollow needle is
passed through the hole, through the brain tissue,
directly into the clot. The hollow needle is
attached to a large syringe, which the surgeon
uses to suction out the contents of the blood
Recovery & prevention
Immediately after an ICH, the
patient will stay in the intensive care unit
(ICU) for several weeks where doctors and nurses
watch them closely for signs of rebleeding,
hydrocephalus, and other complications. Once
their condition is stable, the patient is transferred
to a regular room.
ICH patients may suffer short-term
and/or long-term deficits as a result of the
bleed or the treatment. Some of these deficits
may disappear over time with healing and therapy.
The recovery process may take weeks, months,
or years to understand the level of deficits
incurred and regain function.
Clinical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to see if they are safe and effective. Research is always being conducted to improve the standard of medical care. Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of Health (see clinicaltrials.gov) as well as private industry and pharmaceutical companies (see www.centerwatch.com).
Sources & links
If you have more questions, please
contact the Mayfield Clinic at 800-325-7787
- Broderick JP, Zuccarello M, et al.: Guidelines
for the Management of Spontaneous Intracerebral
Hemorrhage. Stroke 30:905-915, 1999.
- Fewel ME, Thompson BG, Hoff JT: Spontaneous
Intracerebral Hemorrhage:a review. Neurosurg
Focus 15: 2003.
craniotomy: surgical opening
of a portion of the skull to gain access to
intracranial structures and replacement of the
hematoma: a blood clot.
in the brain due to a blockage of cerebrospinal
hypertension: high blood
intracranial pressure (ICP):
pressure within the skull.
ICP monitor: a device used
to measure intracranial pressure inside the
subarachnoid hemorrhage: bleeding in the space
surrounding the brain; may cause a stroke.
transcranial doppler (TCD):
an ultrasound device used to measure blood flow
through an artery.
stereotactic: a precise
method for locating deep brain structures by
the use of 3-dimensional coordinates.
ventricles: hollow areas
in the center of the brain containing cerebrospinal
ventriculoperitoneal (VP) shunt:
a catheter placed in the ventricle of the brain
to drain excess cerebrospinal fluid.
updated > 2.2013
reviewed by > Mario Zuccarello, MD, Mayfield Clinic / University of Cincinnati Department of Neurosurgery, Ohio