Intra-axial hematoma
Encyclopedia
A cerebral hemorrhage or hemorrhage (or intracerebral hemorrhage, ICH) is a subtype of intracranial hemorrhage
that occurs within the brain tissue itself. Intracerebral hemorrhage can be caused by brain trauma
, or it can occur spontaneously in hemorrhagic stroke. Non-traumatic intracerebral hemorrhage is a spontaneous bleeding into the brain tissue.
A cerebral hemorrhage is an intra-axial hemorrhage; that is, it occurs within the brain tissue rather than outside of it. The other category of intracranial hemorrhage is extra-axial hemorrhage, such as epidural, subdural
, and subarachnoid hematomas, which all occur within the skull but outside of the brain tissue. There are two main kinds of intra-axial hemorrhages: intraparenchymal hemorrhage
and intraventricular hemorrhages. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious medical emergency
because they can increase intracranial pressure
, which if left untreated can lead to coma
and death. The mortality rate
for intraparenchymal bleeds is over 40%.
due to a large mass putting pressure on the brain.
Intracerebral hemorrhages are often misdiagnosed as subarachnoid hemorrhage
s due to the similarity in symptoms and signs. A severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage. Some patients may also go into a coma before the bleed is noticed.
Intracerebral bleeds are the second most common cause of stroke
, accounting for 30–60% of hospital admissions for stroke. High blood pressure
raises the risks of spontaneous intracerebral hemorrhage by two to six times. More common in adults than in children, intraparenchymal bleeds due to trauma are usually due to penetrating head trauma, but can also be due to depressed skull fracture
s. Acceleration-deceleration trauma, rupture of an aneurysm
or arteriovenous malformation
(AVM), and bleeding within a tumor
are additional causes. Amyloid angiopathy is a not uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis
. Infection with the k serotype of Streptococcus mutans
may also be a risk factor, due to its prevalence in stroke patients and production of collagen-binding protein.
Risk factors for ICH include:
Tramautic intracerebral Hematomas are divided into acute and delayed. Acute intracerebral Hematomas occur at the time of the injury while delayed intracerebral Hematomas have been reported from as early as 6 hours post injury to as long as several weeks. It is important to keep in mind that intracerebral Hematomas can be delayed because if symptoms begin to appear several weeks after the injury, concussion is no longer considered and the symptoms may not be connected to the injury.
Intraparenchymal hemorrhage can be recognized on CT scans because blood appears brighter than other tissue and is separated from the inner table of the skull by brain tissue. The tissue surrounding a bleed is often less dense than the rest of the brain due to edema
, and therefore shows up darker on the CT scan.
is greater than 3 cm, if there is a structural vascular
lesion
or lobar
hemorrhage
in a young patient.
. Intraparenchymal bleeds within the medulla oblongata
are almost always fatal, because they cause damage to cranial nerve X, the vagus nerve
, which plays an important role in blood circulation and breathing. This kind of hemorrhage can also occur in the cortex
or subcortical areas, usually in the frontal
or temporal lobe
s when due to head injury, and sometimes in the cerebellum
.
For spontaneous ICH seen on CT scan, the death rate (mortality
) is 34–50% by 30 days after the insult, and half of the deaths occur in the first 2 days.
The inflammatory response triggered by stroke has been viewed as harmful, focusing on the influx and migration of blood-borne leukocytes, neutrophils, and macrophages.
New area of interest are the Mast Cells.
in the US, behind cerebral thrombosis (40%) and cerebral embolism (30%).
It is two or more times more prevalent in black American patients than it is in white.
Intracranial hemorrhage
An intracranial hemorrhage is a hemorrhage, or bleeding, within the skull.-Causes:Intracranial bleeding occurs when a blood vessel within the skull is ruptured or leaks. It can result from physical trauma or nontraumatic causes such as a ruptured aneurysm...
that occurs within the brain tissue itself. Intracerebral hemorrhage can be caused by brain trauma
Acquired brain injury
An acquired brain injury is brain damage caused by events after birth, rather than as part of a genetic or congenital disorder such as fetal alcohol syndrome, perinatal illness or perinatal hypoxia. ABI can result in cognitive, physical, emotional, or behavioural impairments that lead to permanent...
, or it can occur spontaneously in hemorrhagic stroke. Non-traumatic intracerebral hemorrhage is a spontaneous bleeding into the brain tissue.
A cerebral hemorrhage is an intra-axial hemorrhage; that is, it occurs within the brain tissue rather than outside of it. The other category of intracranial hemorrhage is extra-axial hemorrhage, such as epidural, subdural
Subdural hematoma
A subdural hematoma or subdural haematoma , also known as a subdural haemorrhage , is a type of haematoma, a form of traumatic brain injury. Blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain...
, and subarachnoid hematomas, which all occur within the skull but outside of the brain tissue. There are two main kinds of intra-axial hemorrhages: intraparenchymal hemorrhage
Intraparenchymal hemorrhage
Intraparenchymal hemorrhage is one extension of intracerebral hemorrhage with bleeding within brain parenchyma....
and intraventricular hemorrhages. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious medical emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
because they can increase intracranial pressure
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
, which if left untreated can lead to coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
and death. The mortality rate
Mortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
for intraparenchymal bleeds is over 40%.
Signs and symptoms
Patients with intraparenchymal bleeds have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed. Other symptoms include those that indicate a rise in intracranial pressureIntracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
due to a large mass putting pressure on the brain.
Intracerebral hemorrhages are often misdiagnosed as subarachnoid hemorrhage
Subarachnoid hemorrhage
A subarachnoid hemorrhage , or subarachnoid haemorrhage in British English, is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain...
s due to the similarity in symptoms and signs. A severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage. Some patients may also go into a coma before the bleed is noticed.
Causes
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
, accounting for 30–60% of hospital admissions for stroke. High blood pressure
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
raises the risks of spontaneous intracerebral hemorrhage by two to six times. More common in adults than in children, intraparenchymal bleeds due to trauma are usually due to penetrating head trauma, but can also be due to depressed skull fracture
Skull fracture
A skull fracture is a break in one or more of the bones in the skull usually occurring as a result of blunt force trauma. If the force of the impact is excessive the bone may fracture at or near the site of the impact...
s. Acceleration-deceleration trauma, rupture of an aneurysm
Aneurysm
An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
or arteriovenous malformation
Arteriovenous malformation
Arteriovenous malformation or AVM is an abnormal connection between veins and arteries, usually congenital. This pathology is widely known because of its occurrence in the central nervous system, but can appear in any location. An arteriovenous malformation is a vascular anomaly. It is a...
(AVM), and bleeding within a tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
are additional causes. Amyloid angiopathy is a not uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis
Cerebral venous sinus thrombosis
Cerebral venous sinus thrombosis is a rare form of stroke that results from thrombosis of the dural venous sinuses, which drain blood from the brain. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body, and...
. Infection with the k serotype of Streptococcus mutans
Streptococcus mutans
Streptococcus mutans is a facultatively aerobic, Gram-positive coccus-shaped bacterium commonly found in the human oral cavity and is a significant contributor to tooth decay.The microbe was first described by J Kilian Clarke in 1924.-Introduction:...
may also be a risk factor, due to its prevalence in stroke patients and production of collagen-binding protein.
Risk factors for ICH include:
- HypertensionHypertensionHypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
- Diabetes
- MenopauseMenopauseMenopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
- Current cigarette smoking
- Alcoholic drinks (≥2/day)
Tramautic intracerebral Hematomas are divided into acute and delayed. Acute intracerebral Hematomas occur at the time of the injury while delayed intracerebral Hematomas have been reported from as early as 6 hours post injury to as long as several weeks. It is important to keep in mind that intracerebral Hematomas can be delayed because if symptoms begin to appear several weeks after the injury, concussion is no longer considered and the symptoms may not be connected to the injury.
Diagnosis
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
, and therefore shows up darker on the CT scan.
Treatment
Treatment depends substantially of the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.Medication
- Antihypertensive therapy in acute phases. The AHA/ASA and EUSI guidelines (American Heart Association/American Stroke Association guidelines and the European Stroke Initiative guidelines) have recommended antihypertensive therapy to stabilize the mean arterial pressureMean arterial pressureThe mean arterial pressure is a term used in medicine to describe an average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle.-Calculation:...
at 110 mmHg. One paper showed the efficacy of this antihypertensive therapy without worsening outcome in patients of hypertensive intracerebral hemorrhage within 3 hours onset. - Giving Factor VIIFactor VIIFactor VII is one of the proteins that causes blood to clot in the coagulation cascade. It is an enzyme of the serine protease class. A recombinant form of human factor VIIa has U.S. Food and Drug Administration approval for uncontrolled bleeding in hemophilia patients...
a within 4 hours limits the bleeding and formation of a hematomaHematomaA hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
. However, it also increases the risk of thromboembolism. - MannitolMannitolMannitol is a white, crystalline organic compound with the formula . This polyol is used as an osmotic diuretic agent and a weak renal vasodilator...
is effective in acutely reducing raised intracranial pressure. - Acetaminophen may be needed to avoid hyperthermiaHyperthermiaHyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate...
, and to relieve headache. - Frozen plasma, vitamin KVitamin KVitamin K is a group of structurally similar, fat soluble vitamins that are needed for the posttranslational modification of certain proteins required for blood coagulation and in metabolic pathways in bone and other tissue. They are 2-methyl-1,4-naphthoquinone derivatives...
, protamineProtamineProtamines are small, arginine-rich, nuclear proteins that replace histones late in the haploid phase of spermatogenesis and are believed essential for sperm head condensation and DNA stabilization. They may allow for denser packaging of DNA in spermatozoon than histones, but they must be...
, or platelet transfusions are given in case of a coagulopathyCoagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
. - FosphenytoinFosphenytoinFosphenytoin is a water-soluble phenytoin prodrug used only in hospitals for the treatment of epileptic seizures....
or other anticonvulsantAnticonvulsantThe anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers, and in the treatment of neuropathic pain. The goal of an...
is given in case of seizures or lobar hemorrhage. - H2 antagonists or proton pump inhibitors are commonly given for stress ulcer prophylaxis, a condition somehow linked with ICH.
- Corticosteroids, in concert with antihypertensives, reduces swelling.
Surgery
Surgery is required if the hematomaHematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
is greater than 3 cm, if there is a structural vascular
Vascular
Vascular in zoology and medicine means "related to blood vessels", which are part of the circulatory system. An organ or tissue that is vascularized is heavily endowed with blood vessels and thus richly supplied with blood....
lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
or lobar
Lobe (anatomy)
In anatomy, a lobe is a clear anatomical division or extension that can be determined without the use of a microscope This is in contrast to a lobule, which is a clear division only visible histologically....
hemorrhage
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
in a young patient.
- A catheterCatheterIn medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
may be passed into the brain vasculature to close off or dilate blood vesselBlood vesselThe blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
s, avoiding invasive surgical procedures. - Aspiration by stereotactic surgeryStereotactic surgeryStereotactic surgery or stereotaxy is a minimally invasive form of surgical intervention which makes use of a three-dimensional coordinates system to locate small targets inside the body and to perform on them some action such as ablation, biopsy, lesion, injection, stimulation, implantation,...
or endoscopic drainage may be used in basal gangliaBasal gangliaThe basal ganglia are a group of nuclei of varied origin in the brains of vertebrates that act as a cohesive functional unit. They are situated at the base of the forebrain and are strongly connected with the cerebral cortex, thalamus and other brain areas...
hemorrhages, although successful reports are limited.
Other treatment
- Tracheal intubationTracheal intubationTracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
is indicated in patients with decreased level of consciousness or other risk of airway obstruction. - IV fluids are given to maintain fluid balanceFluid balanceFluid balance is the concept of human homeostasis that the amount of fluid lost from the body is equal to the amount of fluid taken in. Euvolemia is the state of normal body fluid volume. Water is necessary for all life on Earth...
, using normotonic rather than hypotonic fluids.
Prognosis
The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the brain stemBrain stem
In vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...
. Intraparenchymal bleeds within the medulla oblongata
Medulla oblongata
The medulla oblongata is the lower half of the brainstem. In discussions of neurology and similar contexts where no ambiguity will result, it is often referred to as simply the medulla...
are almost always fatal, because they cause damage to cranial nerve X, the vagus nerve
Vagus nerve
The vagus nerve , also called pneumogastric nerve or cranial nerve X, is the tenth of twelve paired cranial nerves...
, which plays an important role in blood circulation and breathing. This kind of hemorrhage can also occur in the cortex
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...
or subcortical areas, usually in the frontal
Frontal lobe
The frontal lobe is an area in the brain of humans and other mammals, located at the front of each cerebral hemisphere and positioned anterior to the parietal lobe and superior and anterior to the temporal lobes...
or temporal lobe
Temporal lobe
The temporal lobe is a region of the cerebral cortex that is located beneath the Sylvian fissure on both cerebral hemispheres of the mammalian brain....
s when due to head injury, and sometimes in the cerebellum
Cerebellum
The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
.
For spontaneous ICH seen on CT scan, the death rate (mortality
Mortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
) is 34–50% by 30 days after the insult, and half of the deaths occur in the first 2 days.
The inflammatory response triggered by stroke has been viewed as harmful, focusing on the influx and migration of blood-borne leukocytes, neutrophils, and macrophages.
New area of interest are the Mast Cells.
Epidemiology
It accounts for 20% of all cases of cerebrovascular diseaseCerebrovascular disease
Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process...
in the US, behind cerebral thrombosis (40%) and cerebral embolism (30%).
It is two or more times more prevalent in black American patients than it is in white.
External links
- Parent friendly information on IVH in premature babies from The Hospital for Sick Children
- LPCH on Intraventricular
- Information on brain haemorrhage from Headway - the brain injury association UK based charity providing information and support