Classification & external resources

ICD-10	I60.-I62.
ICD-9	430–431
DiseasesDB	29320
MeSH	D002543

A intracranial hemorrhage is a bleed into the substance of the cerebrum.[1] Cerebral hemorrhages can lead to hemorrhagic strokes and are medical emergencies

Intracranial hemorrhages can result from

• epidural hemorrhage
• subdural hemorrhage
• subarachnoid hemorrhage and
• intracerebral hemorrhage.

Intracerebral hemorrhage

Intracerebral hemorrhage, or ICH, accounts for 10 to 15 percent of all strokes (Weibers 2001). It most frequently results from high blood pressure as found in people with hypertension, eclampsia, and abuse of some drugs (Liebeskind, 2004). A third of intracerebral bleeds result in intraventricular haemorrhage, or bleeding within the brain's ventricles (Liebeskind, 2004). ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or even the very deadly subarachnoid hemorrhage (Liebeskind, 2004). The symptoms of intracerebral hemorrhage include a headache, nausea and vomiting, alertness changes, deficiencies in verbal skills, balance, swallowing, coordination, and focusing the eyes.

Subarachnoid hemorrhage

Subarachnoid hemorrhage, which accounts for 5 to 10 percent of strokes, is one of the deadliest type of strokes. While ischemic strokes have a 30-day mortality rate of 20 percent, subarachnoid bleeds kill 40% of their victims in the same time, disabling half the survivors. When a vessel in the arachnoid layer of the meninges bursts, blood enters the subarachnoid space where cerebrospinal fluid (CSF) bathes the brain, contaminating it. Since the brain is quite sensitive to changes in pH, extensive damage can result when the chemical balance of the CSF is disturbed by the blood.

Symptoms of cerebral hemorrhage

A sudden, severe headache is common in hemorrhagic stroke, and is especially indicative of that if accompanied by stiff neck, facial pain, pain between the eyes, vomiting, or altered consciousness (Weibers, 2001). Other signs of hemorrhagic stroke include those that indicate increased intracranial pressure, caused by swelling or collection of blood. These include increased blood pressure, unequal pupils, especially when one pupil is dilated and does not react to light, headache, vomiting, visual disturbances, and decorticate or decerebrate posturing (Yamamoto, 1996).

Pathophysiology

Blood carries plasma proteins, leukocytes and other molecules which damage brain cells when they flood the area. Also, a rise in intracranial pressure exacerbates ischemia by compressing blood vessels and requiring higher blood pressures to force blood into tissues. A positive feedback loop is created: hypoxic tissue swells, and swelling tissue becomes hypoxic .

Treatment

Due to their life-threatening nature, cerebral hemorrhages require immediate neurosurgical evaluation and intervention. Neurosurgeons use specialized examinations for cerebral hemorrhage patients, such as the Hunt and Hess scale, that can help determine the appropriate treatment. Strategies to protect the brain during this type of stroke include blood sugar and blood pressure control, adequate oxygen and intravenous fluids, detection and treatment of the cause of bleeding, and constant monitoring (usually with the Glasgow Coma Scale) and immediate treatment for complications from bleeding into or around the brain.

Cerebral arteriography may be used to determine the cause for bleeding, since some causes may be surgically corrected to reduce the risk of future bleeding. Selected patients with subarachnoid hemorrhage due to a ruptured aneurysm require emergency surgery to "clip" the aneurysm off from the normal brain blood circulation, and they receive nimodipine, a drug shown to reduce incidence of vasospasm, a complication of this type of stroke.

Risk factors

Like ischemic stroke, risk factors for hemorrhagic stroke include inflammation of the heart, hypertension, and arteritis. Atherosclerosis, the main risk factor for ischemic stroke (Cicala 1999), also causes heart disease and arterial rupture, so the presence of arterial fatty deposits is a major risk factor for hemorrhagic stroke as well. Factors that pose a risk for hemorrhagic stroke and not ischemic stroke include anticoagulant or thrombolytic therapy, bleeding disorders like hemophilia and thrombocytopenic purpura, arterial dissection, and cocaine use (Weibers 2001).

Intracerebral hemorrhages may be caused by burst aneurysms or arteriovenous malformations, but are most often caused by hypertension, which can cause the delicate blood vessels in the brain to burst.

Aneurysm, a weakening and ballooning in the wall of one of the brain's arteries, causes 75-90% of subarachnoid bleeds (Weibers, 2001). Aneurysms may put pressure on the brain tissue, but the real trouble occurs when the weakened wall bursts. The area near the Circle of Willis is a common spot for aneurysms: Small branches off the middle cerebral artery are so prone to burst that they are commonly known as "stroke arteries".

Vascular malformations such as arteriovenous malformation (AVM) are another cause of hemorrhagic stroke. AVM is a congenital condition that consists of a tangle of deformed blood vessels and capillaries with thin walls that can rupture (These malformations can cause subarachnoid hemorrhage but more commonly responsible for intracerebral bleeding (Weibers 2001). Vascular malformations and aneurysms usually cause no symptoms and can lie undetected until they cause a stroke. On occasion, they can cause "warning leaks" without actually bursting, causing symptoms like seizure, migraine, or one-sided numbness In moyamoya disease, small blood vessels in a network replace normal blood vessels around base of brain because of stenosis or blockage of large arteries surrounding the brain These blood vessels are delicate and more likely than normal blood vessels to break and cause hemorrhagic stroke.

Unfortunately, some treatments for ischemic stroke aimed at dissolving the occluding blood clot can increase the likelihood of cerebral hemorrhage. Hemorrhagic transformation is the phenomenon in which blood vessels weakened by ischemic stroke rupture to cause hemorrhage in addition (Hemorrhagic transformation can occur without antithrombotics, but they increase the risk (Jauch, 2003).

For poorly understood reasons, pregnancy increases hemorrhagic stroke risk, and women who have just given birth are more than 28 times more likely to suffer hemorrhagic strokes than the average person.

Epidemiology

Though ischemic strokes are more common, the young, though only a small percentage of stroke sufferers, are more likely to have hemorrhagic strokes than ischemic strokes (NINDS 1999).

References

1. Cicala, Roger. The Brain Disorders Sourcebook. Los Angeles, CA: Lowell House, 1999. Electronic reproduction. Boulder, Colo.: NetLibrary, 2000.
2. Jauch, Edward C. 2005. “Acute Stroke Management.” eMedicine.com, Inc. Available.
3. Kapitt W and Lawrence M. The Anatomy Coloring Book. New York, NY: Harper & Row, 1977.
4. Liebeskind, 2004. Intracranial Hemorrhage. Emedicine.com. Available.
5. National Institute of Neurological Disorders and Stroke (NINDS). National Institutes of Health., Stroke: Hope Through Research. June 1999. Available.
6. Nurse-Anesthesia.com. 2002.
7. Stroke Center. 1997-2003. Available.
8. Weibers, D. Stroke-Free for Life: The Complete Guide to Stroke Prevention and Treatment. Harper Collins, New York NY, 2001.
9. Yamamoto, LG. 1996. “Intracranial Hypertension and Brain Herniation Syndromes: Radiology Cases in Pediatric Emergency Medicine" Volume 5, Case 6. Kapiolani Medical Center for Women and Children; University of Hawaii; John A. Burns School of Medicine. Available.

External links

• Cerebral hemorrhage - Cedars-Sinai Health System.
• The statistics of cerebral hemorrhage - Wrongdiagnosis.com

•  • [ e] Circulatory system pathology (, )
Hypertension	Hypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension)
Ischaemic heart disease	Angina pectoris - Prinzmetal's angina - Myocardial infarction - Dressler's syndrome
Pulmonary circulation	Pulmonary embolism - Cor pulmonale
Pericardium	Pericarditis - Pericardial effusion - Cardiac tamponade
Endocardium/heart valves	Endocarditis - Mitral regurgitation - Mitral valve prolapse - Mitral stenosis - Aortic valve stenosis - Aortic insufficiency - Pulmonary valve stenosis
Myocardium	Myocarditis - Cardiomyopathy (Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right ventricular dysplasia
Electrical conduction system of the heart	Heart block: AV block (First degree, Second degree, Third degree) - Bundle branch block (Left, Right) - Bifascicular block - Trifascicular block Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac arrest Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal reentrant, Ventricular) - Atrial flutter - Atrial fibrillation - Ventricular fibrillation - Premature contraction (Atrial, Ventricular) - Sick sinus syndrome
Other heart conditions	Heart failure - Cardiomegaly - Ventricular hypertrophy (Left, Right)
Cerebrovascular diseases	Intracranial hemorrhage/cerebral hemorrhage: Extra-axial hemorrhage (Epidural hemorrhage, Subdural hemorrhage, Subarachnoid hemorrhage) - Intra-axial hematoma (Intraventricular hemorrhages, Intraparenchymal hemorrhage) - Anterior spinal artery syndrome - Binswanger's disease - Moyamoya disease
Arteries, arterioles and capillaries	Atherosclerosis (Renal artery stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic aneurysm) - Aneurysm - Raynaud's phenomenon/Raynaud's disease - Buerger's disease - Arteritis (Aortitis) - Intermittent claudication - Arteriovenous fistula - Hereditary hemorrhagic telangiectasia - Spider angioma
Veins, lymphatic vessels and lymph nodes	Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis, May-Thurner syndrome, Portal vein thrombosis, Venous thrombosis, Budd-Chiari syndrome, Renal vein thrombosis, Paget-Schroetter disease) - Varicose veins (Hemorrhoid, Esophageal varices, Varicocele, Gastric varices, Caput medusae) - Superior vena cava syndrome - Lymph(Lymphadenitis, Lymphedema, Lymphangitis)
See also (, )