Intracerebral Hemorrhage

Intracerebral hemorrhages are the most common types of hemorrhagic stroke, a type of a stroke when a blood vessel in the brain bursts, which causes blood to leak to the brain. Intracerebral hemorrhages occur when there is bleeding in the brain itself. Intracerebral hemorrhages are the deadliest type of stroke. It accounts around 40% of all stroke deaths. Blood vessels carry blood to and from the brain. Arteries or veins can rupture, either from abnormal pressure or abnormal development or trauma.

A stroke occurs when the brain is deprived of oxygen and blood supply. ICH is most commonly caused by hypertension, arteriovenous malformations, diabetes, or head trauma. Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and relieving the pressure on the brain.

## Symptoms

Intracerebral hemorrhages causes the same symptoms as a stroke., like drooping of one side of the face, numbness, paralysis, speech problems, movement problems, blindness in one or both eyes, deafness in one or both ears, and problems with memory, balance, attention, and coordination. However, fainting, loss of consciousness, coma, headaches, nausea/vomiting, and seizures occurs in intracerebral hemorrhages more often than ischemic strokes.

Because the bleed can affect the hypothalamus, which is the part of the brain relating to body temperature, an intracerebral hemorrhage can also cause fever. Fever in intracerebral hemorrhages are usually above 40ºC.

## Causes

The causes of intracerebral hemorrhage include:

* Hypertension: elevated blood pressure may cause tiny arteries to burst inside the brain. Normal pressure is 120/80 mm Hg.
* Diabetes: diabetes usually causes ischemic strokes, but in rare cases, diabetes can also cause ICH.
* Blood thinners: drugs such as coumadin, heparin, and warfarin used to prevent clots in heart and stroke conditions may cause ICH.
* AVM: a tangle of abnormal arteries and veins with no capillaries in between.
* Aneurysm: a bulge or weakening of an artery 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 buildup of protein within the walls of arteries.
* Smoking: smoking can cause ICH.
* Drug usage: alcohol, cocaine and other illicit drugs can cause ICH.
* Spontaneous: ICH by unknown causes.

## Treatment

Intracerebral hemorrhage is treated by 2 categories: medications and surgery.

### Medications

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

* 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

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 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.