Intracerebral hemorrhage (cerebral hemorrhage)

Encephalorrhage, cerebral hemorrhage

An intracerebral hemorrhage is often life-threatening and a medical emergency. Doctors must treat the bleeding into the brain tissue immediately, otherwise the chances of survival are reduced.

It can affect different areas of the brain and take on different dimensions. The symptoms depend on where the intracerebral hemorrhage has formed: Headaches, disturbances of consciousness, movement and speech or signs of paralysis are possible. The causes often lie in long-term high blood pressure, but also in other underlying diseases.

What is an intracerebral hemorrhage?

An intracerebral hemorrhage is a hemorrhage directly in the brain tissue, in which a hematoma forms. It is also abbreviated as IZB or ICB. Cerebral hemorrhage is life-threatening and always a medical emergency. They must be treated immediately. This is because brain pressure increases the more blood accumulates in the brain tissue. Because the brain cannot expand due to the bony skull, the brain tissue and supplying vessels are compressed. Due to the lack of oxygen and nutrients, more and more nerve cells eventually die.

The name “intracerebral hemorrhage” is derived as follows: “intra” means “in” and the Latin word “cerebrum” means “brain”. There are also extracerebral hemorrhages, which do not affect the brain tissue but the three meninges.

Doctors usually divide the ICB as follows:

  • Non-spontaneous intracerebral hemorrhage (traumatic ICB): This is caused by an injury (craniocerebral trauma), such as an accident, a fight or an operation.
  • Spontaneous intracerebral hemorrhage: This occurs without prior injury. Doctors are often unable to find a disease, even if there is a high probability that it is present.
  • Secondary intracerebral hemorrhage: An underlying disease is responsible, such as high blood pressure, vascular malformations or other vascular diseases.

The symptoms of an ICB depend on the location and size of the cerebral hemorrhage. The first signs can be a sudden headache. Reduced alertness, impaired consciousness, nausea, vomiting and signs of paralysis can also indicate a cerebral hemorrhage.

Intracerebral hemorrhage – frequency and age

Experts estimate that around 12 to 15 out of every 100,000 people in the general population suffer an intracerebral hemorrhage every year. ICBs are responsible for about 15 percent of all strokes. This form of cerebral infarction is also known as a hemorrhagic stroke.

Spontaneous ICB accounts for between 9 and 27 percent of all cerebral hemorrhages. The most common cause is long-term high blood pressure, which causes a cerebral vessel to rupture. In contrast, around 85 percent of strokes have a different cause: they are caused by a reduced blood flow due to a narrowed or blocked vessel in the brain (ischemic stroke).

Some more figures on intracerebral hemorrhage:

  • Before the age of 45, spontaneous ICB is relatively rare (less than 2 per 100,000 inhabitants). From this age, however, the risk increases continuously.
  • On average, people fall ill with ICB at around 65 years of age.
  • For people over the age of 80, as many as 350 out of every 100,000 inhabitants are affected. The risk of spontaneous intracerebral hemorrhage in the elderly is around 25 times higher than in the general population.
  • Women and men are affected about equally often. In some studies, however, men predominate, in others women.

Intracerebral hemorrhage: causes and risk factors

The causes of intracerebral hemorrhages can be very different and varied. However, they are not the result of an injury (e.g. accident, fall, fight) or an operation.

There are two forms of spontaneous intracerebral hemorrhage:

  • Cryptogenic: There is probably a cause, but it cannot be proven with current diagnostic methods and knowledge.
  • Idiopathic: There is no known concept of origin that could explain the cause of the bleeding.

Secondary intracerebral hemorrhages, on the other hand, are caused by a disease that can be diagnosed. They account for the majority of cases. Some underlying conditions and triggers that may be associated with secondary ICB:

  • Arterial high blood pressure (hypertension) that persists over a long period of time. The hemorrhage usually affects the basal ganglia, the thalamus, the cerebellum and the bridge (pons). Arterial hypertension is the most important risk factor for ICB.
  • Cerebral amyloid angiopathy – a vascular disease in which proteins (amyloids) are deposited in the blood vessels and narrow their diameter.
  • Diseases of the arteries and small arterioles
  • Diseases of the small and large vessels that are genetically determined or acquired in the course of life
  • Cerebral aneurysm – a vascular aneurysm that can easily rupture
  • Diseases of the veins: e.g. inflammation of the veins (vasculitis), sinus and sinus thrombosis
  • Reversible vasoconstriction syndrome – the muscles of cerebral vessels contract
  • Moyamoya – a vascular disease characterized by progressive narrowing of the cerebral arteries at the base of the brain
  • Vascular malformations, e.g. arteriovenous malformation, dural arteriovenous fistula and cerebral cavernous malformation
  • Tumors and reduced blood flow (ischemia) – the hemorrhages occur as a result (secondary)
  • Coagulation disorders – e.g. blood disorders, also triggered by medical treatments or vitamin K antagonists
  • Infectious inflammation of the inner lining of the heart (endocarditis)
  • Substance abuse, e.g. drugs such as cocaine and amphetamines

Symptoms: Intracerebral hemorrhage causes various symptoms

The symptoms of an intracerebral hemorrhage depend on the extent and location of the hemorrhage. Minor hemorrhages often cause no or hardly any symptoms, for example in the case of amyloid angiopathy. However, severe mass bleeding can also occur if a blood vessel ruptures, for example due to long-standing high blood pressure. These cerebral hemorrhages cause very severe, usually sudden onset symptoms – and can be fatal.

The following symptoms can occur with an ICB – depending on the location of the bleeding:

  • Brain lobe: Headaches, sensory and movement disorders, epilepsy (seizures), visual field defects in both eyes – symptoms worsen as the hemorrhage spreads.
  • Basal ganglia: hemiplegia of the opposite side of the body, eye movement disorders (deflection of both eyes = deviation conjuguée), speech and language comprehension disorders (aphasia), visual impairment with visual field loss in both eyes (homonymous hemianopsia)
  • Thalamus: impaired consciousness, reduced attention, sensory disturbances, gaze paralysis (gaze palsy)
  • Cerebellum: nausea and vomiting, movement coordination disorders, dizziness, uncontrollable and rhythmic eye movements, speech disorders
  • Pons (bridge): Paralysis of all four extremities (tetraparesis), cranial nerve deficits, coma

Based on the symptoms, it is usually not immediately possible to distinguish between an intracerebral hemorrhage and a stroke caused by vascular occlusion and reduced blood flow (ischemic stroke).

Diagnosis of intracerebral hemorrhage

We have to distinguish quickly and reliably between an intracerebral hemorrhage and an ischemic stroke. The therapy depends crucially on this. Treatment is different, especially in the initial phase.

We start by asking a few questions about your medical history (anamnesis). If the person concerned cannot provide any information themselves, they will ask relatives, friends or bystanders. For example, it is important to know what symptoms the patient has, how pronounced they are, where exactly they manifest themselves and when they started. We also ask about existing illnesses, the intake of medication or possible drug use.

Patients with a cerebral haemorrhage must be admitted to hospital as quickly as possible, preferably to a specialized stroke unit. A neurological examination is carried out there, during which they test reflexes and the function of muscles and nerves. The diagnosis of ICB can be made with the help of imaging techniques.

To be used:

  • Computed tomography (CT) of the brain: CT is an X-ray method that provides high-resolution cross-sectional images. Radiologists can thus identify the location and extent of the bleeding.
  • Magnetic resonance imaging (MRI = magnetic resonance imaging): This method works with strong magnetic fields and also provides detailed cross-sectional images of the brain.
  • Angiography (in combination with CT or MRI or digital subtraction angiography) – this allows the vessels in the brain to be visualized

If an intracerebral hemorrhage is suspected, a blood test is necessary:

  • Blood count
  • Inflammation markers
  • Blood coagulation: INR value, partial thromboplastin time = PTT, thrombin time = TZ
  • Electrolytes
  • Kidney and liver values
  • Blood sugar
  • Anti-Xa activity: This provides information about the heparin level, for example when taking oral anticoagulants.
  • Platelet function test when taking platelet aggregation inhibitors such as acetylsalicylic acid (ASA)
  • Drug screening

Intracerebral hemorrhage: prevention, early detection, prognosis

You may be able to prevent an intracerebral hemorrhage if you maintain a healthy lifestyle. You should also have existing underlying illnesses such as high blood pressure, arterial and venous diseases adequately treated.

Some tips:

  • Eat a healthy diet: eat plenty of fresh fruit and vegetables, whole grain products and choose more vegetable fats than animal fats. Also be sparing with animal products such as sausage and meat. Also drink enough, about 1.5 to 2 liters per day (preferably water).
  • Make sure you get enough exercise in your everyday life and take part in sport. Endurance sports such as hiking, swimming, cycling or Nordic walking are good.
  • Give up smoking, and if you smoke: Try to stop smoking. Get professional support if you can’t do it alone. And: very few people succeed in quitting smoking straight away – they try several times.
  • Watch your alcohol consumption and drink as little as possible. Take regular alcohol breaks each week.
  • If you are under a lot of stress, it is best to learn a relaxation method. Examples are autogenic training or progressive muscle relaxation according to Jacobson. Stress affects the body and the blood vessels.
  • Avoid drugs such as cocaine, amphetamines and others.
  • If you are overweight, try to lose a few kilos. This is best achieved with a healthy diet and exercise.
  • Have an existing high blood pressure adequately treated. Make sure that your blood pressure is well controlled in the long term. The same applies to elevated blood lipids and cholesterol levels. Exercise and a healthy diet are good for both your blood pressure and your blood lipids.
  • Sometimes a burst aneurysm is the cause of the intracerebral hemorrhage. It is possible to prevent the rupture of the vessel with an operation. However, such an operation also involves some risks. Discuss the advantages and disadvantages with a doctor.

Targeted medical measures for the early detection of cerebral hemorrhage are not known.

The following is therefore generally advisable: If you are known to have an underlying condition that is associated with a risk of intracerebral hemorrhage, you should have this checked regularly by your doctor. Adequate treatment of this disease is also important. This may make it possible to intervene and prevent a cerebral hemorrhage.

Course and prognosis of intracerebral hemorrhage

The course and prognosis of an intracerebral hemorrhage always depend on the extent and location of the cerebral hemorrhage. If you suspect that you or another person has suffered a brain haemorrhage: Act immediately and call the emergency medical service on 144. The earlier the intracerebral hemorrhage is detected, the better the chances of survival and prognosis.

However, many people do not survive a spontaneous intracerebral hemorrhage because it causes massive damage to the brain tissue. Around one in five people affected die within a day. The mortality rate within 30 days is around 40 percent. After one year, around 50 percent of patients are no longer alive. However, some people regain their independence after an intracerebral hemorrhage and . If the prognosis is unfavorable, a discussion with the patient’s family may follow and palliative care is applied. If necessary, colleagues from the specialist center are also involved.

There are several factors that have an unfavorable effect on the prognosis for ICB, for example:

  • old age
  • Poor general state of health
  • Increase in bleeding within 24 hours
  • Bleeding into the ventricles
  • large blood volume
  • Treatment with anticoagulants
  • Further intracerebral damage

Intracerebral hemorrhage: treatment must begin quickly

Treatment of an intracerebral hemorrhage must begin as soon as possible. This increases the chances of survival and the consequential damage can be kept to a minimum. You should therefore call the emergency medical service (144) at the slightest suspicion of an ICB. It could save the life of the person concerned.