Intracerebral hemorrhage treatment

Intracerebral hemorrhage treatment

What is an intraparenchymal hemorrhage?

Brain hemorrhage symptoms

How is intracranial hemorrhage treated?

What is the best treatment option for hemorrhagic strokes?

What is the most common cause of intracerebral hemorrhage?

Can a person recover from brain hemorrhage?


What is an intraparenchymal hemorrhage?

Intraparenchymal hemorrhage (IPH) is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. The other form is intraventricular hemorrhage (IVH). Intraparenchymal hemorrhage accounts for approx. 8-13% of all strokes and results from a wide spectrum of disorders. It is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage, and therefore constitutes an immediate medical emergency.


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Brain hemorrhage symptoms

Although headache is frequently associated with bleeding in the brain, it is not always present. Most often, the symptoms associated with a brain hemorrhage are dependent on the particular area of the brain that is involved. If the bleeding is in the part of the brain associated with vision, there may be problems seeing. Problems with balance and coordination, weakness on one side, numbness, or sudden seizure may occur. The speech center for many people is located in the left side of the brain and bleeding into this area may cause marked speech disturbances. If the bleeding is in the lower brain (brainstem), where most of the automatic body functions are regulated, a patient may become unresponsive or go into a coma. Additionally, sometimes symptoms of brain hemorrhage may come on very abruptly and rapidly worsen. Alternatively, the symptoms may progress slowly over many hours or even days.



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What is the most common cause of intracerebral hemorrhage?

High blood pressure is the most common cause of ICH. In younger people, another common cause is abnormally formed blood vessels in the brain.

Other causes include:

  • head injury or trauma
  • ruptured cerebral aneurysm (a weak spot in a blood vessel that bursts)
  • arteriovenous malformation (a grouping of malformed blood vessels in your brain that disrupts normal blood flow)
  • use of blood thinners
  • bleeding tumors
  • cocaine or methamphetamine use (which can cause severe hypertension and lead to hemorrhage)
  • bleeding disorders (for example, hemophilia or sickle cell anemia)

Anyone can have an ICH, but your risk increases with age. men are at slightly higher risk than women.









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How is intracranial hemorrhage treated?

Any type of bleeding inside the skull or brain is a medical emergency. It is important to get the person to a hospital emergency room immediately to determine the cause of the bleeding and begin medical treatment.

If a stroke has occurred, the cause (bleeding or blood clot) must be determined so that the appropriate treatment can be started. Prompt medical treatment can minimize damage to the brain, thereby improving the patient's chance of recovery.



Medical treatment

The patient will stay in the stroke unit or intensive care unit (ICU) for close monitoring and care.

  • If the patient was on blood thinners, reversal drugs will be given to restore clotting factors.
  • Blood pressure is managed to decrease the risk of more bleeding yet provide enough blood flow (perfusion) to the brain.
  • Controlling intracranial pressure is a factor in large bleeds. A device called an ICP monitor may be placed directly into the ventricles or within the brain to measure pressure. Normal ICP is 20mm HG.
  • Removing cerebrospinal fluid (CSF) from the ventricles helps control pressure. A ventricular catheter (VP shunt) may be placed to drain CSF fluid and 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.

Surgery may be necessary in the following situations:

  • Hemorrhage may require immediate decompression of the brain to release pooled blood and relieve pressure. Decompression may be done through a burr hole procedure (drilling a hole in the skull to allow blood drainage), a craniectomy incision (partial removal of the skull to allow the swelling brain to expand), or a craniotomy (opening of the skull cavity).
  • Hemorrhage caused by a ruptured cerebral aneurysm requires clipping of the aneurysm through a craniotomy surgical procedure, as soon as the patient's neurological condition permits.


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Other treatments may include:

  • Anti-anxiety drugs and/or medication to control blood pressure
  • Anti-epileptic drugs for seizure control
  • Other medications necessary to control other symptoms, such as painkillers for severe headache and stool softeners to prevent constipation and straining during bowel movements
  • Nutrients and fluids as necessary- These may be given through a vein (intravenously), or a feeding tube in the stomach (gastronomy tube), especially if the patient has difficulty swallowing



Surgical treatment

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 clot aspiration is a minimally invasive surgery for large hematomas located deep inside the brain. The procedure uses a stereotactic frame to guide a needle or endoscope directly into the clot. Stereotactic guidance is like the GPS system in your car. It is a navigation based on your presurgical imaging scans. The CT scan helps pinpoint the best trajectory into the hematoma. In the OR, the surgeon drills a small burr hole about the size of quarter in the skull. With the aid of the stereotactic frame, a hollow cannula is passed through the hole, through the brain tissue, directly into the clot. The hollow cannula is attached to a large syringe to withdraw the liquid portion of the blood clot (Fig. 2). A smaller catheter is then inserted to continue draining over the next days to weeks (Fig. 3).



What is the best treatment option for hemorrhagic strokes?

Emergency treatment for stroke depends on whether you're having an ischemic stroke or a stroke that involves bleeding into the brain (hemorrhagic).

Ischemic stroke

To treat an ischemic stroke, doctors must quickly restore blood flow to your brain. This may be done with:

  • Emergency IV medication.Therapy with drugs that can break up a clot has to be given within 4.5 hours from when symptoms first started if given intravenously. The sooner these drugs are given, the better. Quick treatment not only improves your chances of survival but also may reduce complications.

An IV injection of recombinant tissue plasminogen activator (tPA)  also called alteplase (Activase)  is the gold standard treatment for ischemic stroke. An injection of tPA is usually given through a vein in the arm with the first three hours. Sometimes, tPA can be given up to 4.5 hours after stroke symptoms started.

This drug restores blood flow by dissolving the blood clot causing your stroke. By quickly removing the cause of the stroke, it may help people recover more fully from a stroke. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if tPA is appropriate for you.

  • Emergency endovascular procedures.Doctors sometimes treat ischemic strokes directly inside the blocked blood vessel. Endovascular therapy has been shown to significantly improve outcomes and reduce long-term disability after ischemic stroke. These procedures must be performed as soon as possible:

-Medications delivered directly to the brain. Doctors insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain to deliver tPA directly where the stroke is happening. The time window for this treatment is somewhat longer than for injected tPA, but is still limited.

-Removing the clot with a stent retriever. Doctors can use a device attached to a catheter to directly remove the clot from the blocked blood vessel in your brain. This procedure is particularly beneficial for people with large clots that can't be completely dissolved with tPA. This procedure is often performed in combination with injected tPA.

The time window when these procedures can be considered has been expanding due to newer imaging technology. Doctors may order perfusion imaging tests (done with CT or MRI) to help determine how likely it is that someone can benefit from endovascular therapy.

Other procedures

To decrease your risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that's narrowed by plaque. Options vary depending on your situation, but include:

  • Carotid endarterectomy.Carotid arteries are the blood vessels that run along each side of your neck, supplying your brain (carotid arteries) with blood. This surgery removes the plaque blocking a carotid artery, and may reduce your risk of ischemic stroke. A carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
  • Angioplasty and stents.In an angioplasty, a surgeon threads a catheter to your carotid arteries through an artery in your groin. A balloon is then inflated to expand the narrowed artery. Then a stent can be inserted to support the opened artery.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in your brain caused by the excess fluid. Treatment options include:

  • Emergency measures. If you take blood-thinning medications to prevent blood clots, you may be given drugs or transfusions of blood products to counteract the blood thinners' effects. You may also be given drugs to lower the pressure in your brain (intracranial pressure), lower your blood pressure, prevent spasms of your blood vessels and prevent seizures.
  • Surgery. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on your brain. Surgery may also be used to repair blood vessel problems associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if an aneurysm, arteriovenous malformation (AVM) or other type of blood vessel problem caused your hemorrhagic stroke:
  • Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep an aneurysm that has recently hemorrhaged from bleeding again.
  • Coiling (endovascular embolization). Using a catheter inserted into an artery in your groin and guided to your brain, your surgeon will place tiny detachable coils into the aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.
  • Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of your brain. This eliminates the risk of rupture and lowers the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's located deep within the brain, it's large, or its removal would cause too much of an impact on brain function.
  • Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair blood vessel malformations.


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Can a person recover from brain hemorrhage?

Many patients who have experienced a brain hemorrhage do survive. However, survival rates are decreased when the bleeding occurs in certain areas of the brain or if the initial bleed was very large.

If a patient survives the initial event of an intracranial hemorrhage, recovery may take many months. Over time and with extensive rehabilitation efforts, including physical, occupational, and speech therapy, patients can regain function. However, some can be left with persistent weakness or sensory problems. Other patients may have residual seizures, headaches, or memory problems.


10 common questions about Intracerebral hemorrhage treatment

1Can you survive intracerebral hemorrhage?
Many patients who have experienced a brain hemorrhage do survive. However, survival rates are decreased when the bleeding occurs in certain areas of the brain or if the initial bleed was very large. If a patient survives the initial event of an intracranial hemorrhage, recovery may take many months
2Can cerebral hemorrhage be treated?
Treatment for bleeding in the brain depends on the location, cause, and extent of the hemorrhage. Surgery may be needed to alleviate swelling and prevent bleeding. ... These include painkillers, corticosteroids, or diuretics to reduce swelling, and anticonvulsants to control seizures
3What is the difference between intracranial and intracerebral hemorrhage?
An intracranial hemorrhage is a type of bleeding that occurs inside the skull (cranium). Bleeding around or within the brain itself is known as a cerebral hemorrhage (or intracerebral hemorrhage). Bleeding caused by a blood vessel in the brain that has leaked or ruptured (torn) is called a hemorrhagic stroke.
4What are 3 types of hemorrhage?
Note that there are three different types of hemorrhage in the same patient: subdural hematoma, intraparenchymal hemorrhage (from contusion), and subarachnoid blood.
5How long can you live with brain hemorrhage?
Hemorrhagic stroke is life threatening. Many of these deaths occur within the first two days. For those who survive a brain hemorrhage, recovery is slow. A minority of people are able to recover complete or near-complete functioning within 30 days of the stroke.
6How long do you live after a hemorrhagic stroke?
The survival rate after hemorrhagic stroke was 26.7% within a period of five years. Long-term survival rate prognosis is significantly better among the younger patients, without hypertension, alcohol intake and diabetes mellitus
7Why are hemorrhagic strokes worse than ischemic?
Those who suffer ischemic strokes have a much better chance for survival than those who experience hemorrhagic strokes, as hemorrhagic stroke not only damages brain cells but also may lead to increased pressure on the brain or spasms in the blood vessels [9]
8What is the life expectancy after a hemorrhagic stroke?
The estimated survival rate for hemorrhagic strokes is around 26.7%. If you think about it, that is basically 1 in every 4 people that have a hemorrhagic stroke. It is believed that a survival rate for diseases and conditions is life after 5 years after the stroke occurred or longer.
9What is the most common cause of intracerebral hemorrhage?
Intracerebral hemorrhage (ICH) is caused by bleeding within the brain tissue itself — a life-threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood supply. ICH is most commonly caused by hypertension, arteriovenous malformations, or head trauma.
10Is surgery necessary for brain hemorrhage?
Surgery may be necessary to treat a severe brain hemorrhage. Surgeons may operate to relieve some of the pressure on the brain. If a burst cerebral aneurysm causes a hemorrhage, a surgeon may remove part of the skull and clip the artery. This procedure is called a craniotomy.


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