Brain hamorage
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Brain Hemorrhage (Intracranial Hemorrhage)
Definition
A brain hemorrhage is any bleeding within the skull - also called intracranial hemorrhage (ICH). It accounts for about 13% of strokes in the US and ~20% worldwide (higher in countries where hypertension is prevalent but atherosclerosis is less common).
Types and Locations
There are four main types based on the anatomical location of bleeding:
| Type | Location | Common Cause |
|---|---|---|
| Epidural hemorrhage | Between dura mater and skull | Meningeal artery tear (usually trauma) |
| Subdural hemorrhage | Between dura and arachnoid | Torn bridging veins (trauma, elderly falls) |
| Subarachnoid hemorrhage (SAH) | Subarachnoid space around brain surface | Ruptured aneurysm, trauma |
| Intracerebral/Intraparenchymal hemorrhage | Within brain tissue itself | Hypertension, amyloid angiopathy |
- Intracerebral hemorrhage makes up ~75% of hemorrhagic strokes; SAH makes up ~25%.
- Intraventricular hemorrhage (blood within the brain's ventricles) occurs in ~40% of cases as a secondary extension.
Causes
The most common causes, in order of frequency (Adams and Victor's Principles of Neurology, 12th Ed.):
- Primary hypertensive intracerebral hemorrhage - the #1 cause; due to rupture of small penetrating arteries (Charcot-Bouchard microaneurysms)
- Ruptured saccular (berry) aneurysm - leads to SAH; ~80% occur at circle of Willis bifurcations
- Ruptured arteriovenous malformation (AVM)
- Anticoagulant/thrombolytic therapy - increasingly common
- Cerebrovascular amyloid angiopathy - increasingly important as hypertension is better controlled
- Hemorrhagic bleeding disorders - leukemia, thrombocytopenia, liver disease, hemophilia
- Brain tumors (primary or metastatic)
- Trauma ("coup-contrecoup" mechanism)
- Cocaine, RCVS (reversible cerebral vasoconstriction syndrome), PRES, vasculitis, mycotic aneurysm, and others
Most common sites for spontaneous hemorrhage:
- Putamen and adjacent internal capsule (50%)
- Lobar white matter (temporal, parietal, frontal)
- Thalamus
- Cerebellar hemisphere
- Pons
Clinical Features (Symptoms)
The classic presentation is of rapid but not instantaneous hemiplegia - historically called "apoplexy":
- Sudden severe headache ("thunderclap" - especially in SAH; "worst headache of my life")
- Acute hemiplegia / focal weakness on one side
- Vomiting at onset - occurs much more often in hemorrhage than ischemic stroke
- Acute reactive hypertension - BP often spikes far above baseline
- Altered consciousness / coma - especially with large or deep bleeds
- Seizures - focal, occur in ~10% of supratentorial hemorrhages within the first few days
- Nuchal rigidity - more common in SAH
Key clinical distinguisher: Hemorrhage typically has vomiting + headache + hypertension at onset. Ischemic stroke is more gradual, without those features.
Small bleeds may present like ischemic strokes ("talk and die" pattern) - patients who appear well initially can deteriorate rapidly as contusions expand over hours to days.
Pathophysiology
When bleeding occurs, blood accumulates and exerts mass effect on surrounding brain tissue. The Monro-Kellie doctrine explains this: the skull is a fixed space, so any increase in blood volume displaces brain tissue and CSF, raising intracranial pressure (ICP). If pressure builds enough, cerebral herniation occurs - the brain is pushed downward through the foramen magnum or across the tentorium/falx. This is life-threatening.
Additionally, blood is directly toxic to neurons - causing edema, inflammation, and further secondary injury in the surrounding tissue.
Diagnosis
- CT scan (non-contrast) - first-line, fast, shows fresh blood as a bright (hyperdense) area
- MRI - better for detecting small or subacute bleeds, diffuse axonal injury, amyloid angiopathy
- CT angiography / MR angiography - identifies aneurysms or AVMs as the source
- Lumbar puncture - used if CT is negative but SAH is still suspected (shows xanthochromia)
Severity Scoring
The ICH Score (range 0-6) is widely used to estimate 30-day mortality:
| ICH Score | Estimated Mortality |
|---|---|
| 0 | 0% |
| 1 | 13% |
| 2 | 26% |
| 3 | 72% |
| 4 | 97% |
| 5+ | 100% |
Points assigned for: low GCS, ICH volume ≥30 mL, age ≥80, infratentorial location, intraventricular extension.
Treatment
Medical management:
- Blood pressure control - rapid but controlled lowering (target SBP <140 mmHg) reduces hematoma expansion
- Reversal of anticoagulation - IV vitamin K, prothrombin complex concentrate (PCC), or specific reversal agents (e.g., idarucizumab for dabigatran)
- ICP management - head elevation, osmotic therapy (mannitol, hypertonic saline), avoid hypoxia
- Blood glucose and temperature control
- Seizure prophylaxis is NOT routinely recommended
Surgical management:
- Epidural and subdural hematomas - urgent surgical decompression/evacuation (craniotomy or burr hole) is the standard for large or symptomatic cases
- Intracerebral hemorrhage - surgical benefit is less clear for most deep hemorrhages; cerebellar hemorrhages >3 cm with neurological deterioration are a clear surgical indication
- SAH from aneurysm - surgical clipping or endovascular coiling of the aneurysm
Complications to watch for:
- Rebleeding (especially from aneurysm in SAH)
- Cerebral vasospasm (SAH) - onset 4-14 days, treated with nimodipine
- Hydrocephalus
- Herniation
Prognosis
Outcome depends on: location, volume of bleed, GCS at presentation, age, and cause. Cerebellar hemorrhages are more amenable to surgery. Large putaminal or thalamic bleeds carry poor prognosis. Overall 30-day mortality for ICH is approximately 30-50%.
Sources: Adams and Victor's Principles of Neurology, 12th Ed. | Goldman-Cecil Medicine | Sabiston Textbook of Surgery
Note: This is educational information. Brain hemorrhage is a medical emergency - if you or someone else has sudden severe headache, weakness, confusion, or loss of consciousness, call emergency services (911) immediately.
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