Bleeding Inside the Brain: Intracerebral Hemorrhage

 Bleeding Inside the Brain: Intracerebral Hemorrhage

There are many different types of strokes, but they all hurt the brain by stopping blood flow. Strokes can induce varied symptoms depending on which area of the brain was hurt. This is because different parts of the brain are good at doing different things. One patient can have weakness on one side of their body as a symptom. In another case, there could be a partial loss of sight. In another case, the person can't talk. And the severity of the symptoms might range from mild to severe, depending on how big the damaged area is and where it happened.

Another important difference between strokes is whether they are caused by a blocked blood artery or a hemorrhage. Most strokes happen because of the first type, which is when brain tissue is injured because blood isn't flowing properly. This is termed an infarction. But 10–15% of strokes involve bleeding from broken blood arteries in the brain tissue. Hemorrhagic strokes (intracerebral hemorrhages) can be even worse than infarctions.

Ariel Sharon, who had a hemorrhagic stroke while he was still prime minister of Israel, is a well-known person who had a spontaneous intracerebral hemorrhage. Some persons with intracerebral hemorrhage get well to the point where they may enjoy being around other people and regain some independence in their daily lives. However, Sharon's poor clinical result is all too frequent in people with this disease.

Another problem with hemorrhagic strokes is that the new blood takes up space—sometimes a lot of it—and there isn't much room in the skull (braincase) for it to go. The new bleeding pushes and changes the brain tissue around it, and it also puts more pressure on the rest of the brain, which can be harmful on its own. Because of these changes in pressure and shape, a person with intracerebral hemorrhage often has a lower degree of consciousness or perhaps goes into a coma.

Subarachnoid hemorrhage is another type of spontaneous bleeding in the braincase. It is commonly caused by aneurysms that have broken outside the brain but inside the braincase. This is also a very serious condition, but it is not the main topic of this essay. Aneurysms like this do not induce spontaneous intracerebral hemorrhages. Secondary hemorrhage is another type of bleeding that might seem like initial intracerebral hemorrhage. This happens to some people who had brain infarctions at first but then had bleeding from weak blood vessels around the borders of the infarction. This type of bleeding isn't as bad as the major bleeding, which is the first incident.

How do doctors find out if someone has an intracerebral hemorrhage? Since the 1970s, when computed tomographic (CT) scans were first used, this imaging method has been the best and most accurate. CT images show a new hemorrhage in brain tissue quite clearly. And whereas infarctions may not show up on CT scans for a day or two, hemorrhages are obvious as soon as a scan can be done.

Removing blood clots from the surface of the brain with surgery, which is known as subdural and epidural hematomas, can save lives and keep people from losing function. However, surgery for a bleed (hematoma or blood clot) inside the brain tissue itself is a different story. Some research that looked at the outcomes of patients with intracerebral hemorrhage who had surgery and those who didn't found that, on average, the outcomes were better for the operated patients. Other studies, however, found that the outcomes were worse for the operated patients. Patients experienced significant rates of death and disability, whether they had surgery or not.

Surgery for intracerebral hemorrhage is often done out of desperation because there aren't many other options for improvement. One grumpy old doctor was very clear about how bad things were. He said, "Show me a patient with intracerebral hemorrhage whose life was saved by surgery, and I'll show you a patient you wish you hadn't operated on." He was trying to make the point that those who survive this surgery frequently have serious problems.

Bleeding in the cerebellum, which is located in the bony braincase immediately above the nape of the neck, is possibly a unique case of bleeding in brain tissue. Removing blood clots from the cerebellum through surgery stops too much pressure from building up on the brainstem, which controls many basic and important activities, such as breathing.

Giving people with the same ailment cortisol-type steroids is a non-surgical treatment that has been scientifically investigated by comparing treated and untreated patients. The steroids didn't work. Researchers have also looked into giving patients medication to lower their blood pressure, but the results were the same: no effect. But in an early investigation, one nonsurgical treatment looked promising. Giving activated factor VII (a natural part of the blood-clotting system) through an IV within four hours after the first hemorrhage stopped the intracerebral blood clot from growing, and it also stopped mortality and disability. There is a bigger study going on to evaluate if this benefit still holds up after more research.

What more can be done right now for this condition? It makes sense to tailor treatment to each person, even when there is no proof that it works. For instance, if the patient was on a blood thinner and had a bleed (as Ariel Sharon did), it seems sense to stop the blood thinner or reverse its effects. It also makes sense to give supportive care, like giving the patient IV fluids to keep them from getting dehydrated, watching for irregular heartbeats, and keeping their airway safe. If the patient can't eat normally, feeding them through tubes or IV lines may be an option. However, this choice can be put off until the patient's condition becomes clearer.

Who is most likely to have an intracerebral hemorrhage? To find risk variables, neurologists at Malmo University Hospital in Malmo, Sweden, looked at 147 patients with intracerebral hemorrhage and 1029 patients who were similar but did not have a stroke. They observed that people with intracerebral hemorrhage were more likely to have high blood pressure, diabetes, high triglyceride levels in the blood, a history of mental health problems, smoking, and (surprise) being short.

When it comes to modifiable risk factors, though, a number of studies show that high blood pressure is the most crucial one. So, treating high blood pressure, if you have it, is probably the best way to stop this condition from happening.

Gary Cordingley, 2006

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