Cerebral Hemorrhage: Causes, Symptoms & Treatment

Cerebral hemorrhage is a generic term for the so-called intracranial hemorrhage (brain hemorrhage inside the skull), intracerebral hemorrhage (brain hemorrhage in the area of the brain) and extracerebral hemorrhage (brain hemorrhage of the meninges). However, in a narrower sense, it usually refers to intracerebral hemorrhage directly in the brain.

What is cerebral hemorrhage?

Schematic diagram showing the anatomy and structure of the brain. Click to enlarge. Cerebral hemorrhage is an umbrella term for three different types of bleeding that can occur in the area of the skull and brain. There is a distinction between intracranial brain hemorrhage, intracerebral brain hemorrhage, and extracerebral brain hemorrhage. In intracerebral cerebral hemorrhage, the bleeding is located in the brain. Usually this occurs spontaneously and is not caused by trauma (accident). In this case, bleeding occurs into the parenchyma (brain tissue). The hemorrhage is classified according to its cause, severity and localization in the brain tissue. Intracranial cerebral hemorrhage is also called epidural hemorrhage. This comes in two forms, arterial epidural hematoma and venous fracture hematoma. Arterial epidural hematoma occurs as a result of traumatic brain injury in which the arterial vessels lying on the inside of the skull bone rupture. In venous fracture hematoma, blood seeps through the fracture gap of a skull fracture into the so-called epidural space and accumulates there. In extracerebral cerebral hemorrhages, a distinction is made between subdural hemorrhage and subarachnoid hemorrhage. Subdural hemorrhage – also known as subdural hematoma – is a hematoma under the meninges that can occur as a result of skull injury. Subarachnoid hemorrhage occurs under the arachnoid (spider tissue membrane). In this type of cerebral hemorrhage, cerebrospinal fluid (CSF) is detectable, unlike the other hemorrhages.

Causes

The causes of a cerebral hemorrhage can be very diverse. Usually, a cerebral hemorrhage occurs as a result of trauma, such as a traffic accident, fall, etc. Furthermore, diseases can also be the cause of a cerebral hemorrhage. In particular, high blood pressure (hypertension), vasculitis (inflammation of the blood vessels), aneurysm, amyloid angiopathy (disease of the blood vessels in the brain) as well as coagulation disorders are possible causes. Cerebral hemorrhage may also have a genetic cause. Vascular malformations – malformations of the blood vessels – are congenital. Brain tumors, as well as vascular tumors, can cause brain hemorrhages. The use of certain medications can also trigger a cerebral hemorrhage. In particular, the group of drugs known as anticoagulants should be mentioned here. Well-known drugs in this group are heparin and phenprocoumon. Long-term alcohol and/or drug consumption favor the development of a cerebral hemorrhage. If no cause for a cerebral hemorrhage is found, it is called a spontaneous cerebral hemorrhage.

Symptoms, complaints, and signs

Depending on which area of the brain is affected by the cerebral hemorrhage, different symptoms may occur. A brain hemorrhage is usually manifested by a sudden, very severe headache. These are accompanied by nausea and vomiting as well as impaired consciousness. Depending on the type and severity of the hemorrhage, stiffening of the neck may occur, associated with neurological deficits. In the course of the cerebral hemorrhage, there is usually an increasing feeling of dizziness, which in turn manifests itself in problems with balance and coordination and is associated with an increased risk of accidents and falls. Visual disturbances, such as seeing double images, blurred vision or temporary loss of vision in one or both eyes, are also typical. In addition, speech disorders, impaired speech and swallowing difficulties may occur, always depending on which area of the brain is affected and the severity of the cerebral hemorrhage. Furthermore, a brain hemorrhage can cause psychological complaints, for example confusion, unexplained behavioral changes or changes in feelings. In the case of large hemorrhages, a clouding of consciousness sets in after a few minutes. In the further course, a cerebral hemorrhage causes seizures, numbness and finally circulatory collapse. If the affected person does not receive intensive medical treatment by then at the latest, there is an acute risk of death. If treatment is delayed too long, complications may occur and sometimes late effects may remain.

Diagnosis and course

Cerebral hemorrhage is diagnosed using imaging techniques.CT, X-ray and MRI are used. In primary care, a CT scan is usually performed because it can be obtained more quickly than an MRI. The location as well as the size of the brain hemorrhage is determined. The increase in size of the brain hemorrhage is checked by another CT scan at a later time. Since time plays a very important role in brain hemorrhage and the general condition of the patient is usually very limited, magnetic resonance imaging (MRI) is not performed until the patient has been stabilized. MRI can also be used to visualize older hemorrhages by means of a contrast medium. Furthermore, this procedure can also visualize the vessels so that an aneurysm or other malformations can be detected. The course of a cerebral hemorrhage depends on many factors. These factors include the age and general condition of the affected person, current constitution, underlying diseases, location of the cerebral hemorrhage, and its size and rate of expansion. For smaller hemorrhages, the mortality rate is approximately 30 to 50%. In the case of extensive cerebral hemorrhage and negative health factors (see above), the prognosis tends to be poor. If affected persons survive the cerebral hemorrhage and also any secondary hemorrhages that may occur, permanent damage such as paralysis, speech disorders, and other mental and physical disabilities are always the result.

Complications

A brain hemorrhage is already a serious complication of another cause. If a brain hemorrhage occurs, severe clouding of consciousness and neurologic deficits usually follow. Affected persons usually experience attention, learning and memory disorders, disorientation and disturbances in the sequence of movements and actions. Depending on the extent of the cerebral hemorrhage, epileptic seizures, regulatory disorders (for example, of body temperature) and spasticity may also occur. Visual field defects, perceptual disorders and dysphagia can also occur as a result of a cerebral hemorrhage and cause further complications. As the condition progresses, it eventually leads to paralysis of the cardiovascular system and coma or death of the affected person. Depending on the type and severity of the cerebral hemorrhage, treatment may be associated with a variety of further complications. For example, the affected person may have to be placed in an artificial coma, which is often associated with permanent consequential damage. Long-term ventilation in a coma can also lead to pneumonia and nerve damage in the arms and legs. In addition, adverse sequelae such as muscle atrophy and impaired cerebrospinal fluid circulation are possible, which can sometimes cause further nerve and brain damage. After awakening, an acute state of confusion (delirium) may remain.

When should you see a doctor?

Cerebral hemorrhage is a medical emergency. As soon as the patient suffers a head injury and exhibits noticeable symptoms, such as memory lapses or vomiting, an emergency physician must be called. Until the ambulance arrives, remain calm as well as apply first aid measures. In case of headache, fainting or disturbance of consciousness, a doctor must be consulted. If there is dizziness, unsteadiness of gait or circulatory problems, there is cause for concern. A physician should be consulted if the symptoms occur without an apparent reason or short-term overuse. In case of amnesia, memory lapses or diffuse memory, a medical examination must be initiated as soon as possible. Behavioral abnormalities, changes in personality or speech disorders are considered warning signs that should be taken seriously. If coordination problems, visual disturbances or sensory disturbances occur, the affected person needs help. Particularly noticeable are phenomena such as pupils of different sizes or general weakness on one side of the body or rising blood pressure. In the case of these symptoms, a medical examination is urgently required. Since a cerebral hemorrhage can, in the worst case, lead to the premature death of the affected person, fast and good medical care is necessary. If the first abnormalities occur suddenly, a visit to the doctor or hospital should be made immediately. If a rising sensation of pressure inside the head is noticed, urgency is required and a physician should be contacted.

Treatment and therapy

Time is of the essence when treating a cerebral hemorrhage.The longer it takes for the affected person to receive care, the more likely it is that he or she will not survive the cerebral hemorrhage. If a cerebral hemorrhage is suspected, immediately go to the nearest hospital or call the emergency physician. Treatment of cerebral hemorrhage is divided into acute treatment and long-term treatment. Depending on the cause, acute treatment may be as follows. Since the brain hemorrhage limits brain functions, the affected person usually needs artificial respiration. If there is an increase in pressure due to the cerebral hemorrhage, surgical intervention is performed. This involves opening part of the skull bone in the affected area. Subsequently, the hematoma is removed. Furthermore, the bleeding is stopped. If, for example, a coagulation disorder is the cause, blood products are administered to normalize blood coagulation. In particular, fresh plasma concentrates are used for this purpose. If excessive blood pressure is the cause, various drugs are used to lower the blood pressure. If the hemorrhage is extensive, it may also be necessary to remove the hematoma by means of surgery. In the case of a subarachnoid hemorrhage, there is a risk of so-called hydrocephalus (brain water retention), which must also be treated by means of neurosurgical intervention. Long-term treatment begins when the affected person has survived the critical phase. This treatment usually includes a lengthy neurological rehabilitation. With the help of various measures, an attempt is made to eliminate the neurological and physical dysfunctions. Depending on how severe the cerebral hemorrhage was and how quickly the treatment was given, it may take several years before the affected person is able to care for himself again independently. In many cases, however, residual symptoms remain after a brain hemorrhage.

Outlook and prognosis

Cerebral hemorrhage is a serious condition whose prognosis is associated with various factors. First of all, this is the severity of the appearance. Relevant to the outlook in this context is not only the spread of the cerebral hemorrhage, but also whether it is a single area of bleeding in the brain or several. For this purpose, it is important in which area of the brain the cerebral hemorrhage has occurred. If important areas of the brain are affected, functional disorders such as paralysis, speech disorders or other symptoms are often difficult to reverse. It is important that a brain hemorrhage is treated competently at an early stage. Therefore, the period between the occurrence of the brain hemorrhage and the start of treatment also plays a major role. The longer the start of treatment is delayed, the more time the brain hemorrhage has to spread. This may mean irreversible damage to the patient. For the patient’s prognosis, it is also important what his general condition is and whether there are any relevant pre-existing or concomitant diseases. The cerebral hemorrhage puts the patient in a frequently critical condition, which can be survived the better the general condition. An increased tendency to bleed or patients who are dependent on Marcumar or other medications to thin the blood are factors that can, in turn, significantly worsen the prognosis of cerebral hemorrhage, however.

Prevention

Cerebral hemorrhage can be prevented with the help of the following measures. To avoid cerebral hemorrhage as a result of trauma, the general known measures for accident prevention in the field of work, sports, everyday life and traffic should always be followed. To reduce the risks of other brain hemorrhages, care should be taken to exercise and avoid obesity. In particular, obesity and no physical activity promote hypertension. Furthermore, regular health checks should be done if there is a family history of cerebral hemorrhage, stroke, heart attack, hypertension, blood clotting disorders, etc. If high blood pressure, diabetes or other diseases are present, they should be treated with medication and monitored by a doctor. A healthy and balanced diet, sufficient exercise and perception of the general preventive medical checkups, are a good measure to prevent cerebral hemorrhage.

Follow-up care

Patients who have survived a cerebral hemorrhage require follow-up care. The intensity of this depends on the extent, age, and state of consciousness of the affected person. It is not uncommon for prolonged therapy to be necessary to correct dysfunction. Neurological and physical processes often have to be relearned.Doctors prescribe prescriptions for this purpose and document the progress of the treatment. The patient’s experience plays a major role in the therapy approaches. In addition, imaging techniques such as CT and MRI are used. Not all patients make a full recovery. Older patients in particular have a low regeneration potential. Aftercare is then aimed at keeping complications to a minimum or pointing out alternatives. What remains are disturbances in concentration and motor function. Changes in character are also sometimes encountered. As far as possible, medication can bring about an improvement. The attending physician regularly adjusts the dosage. A cerebral hemorrhage can occur again and again. Therefore, it is important to exclude causes. Increased blood pressure is considered a risk factor. Many doctors therefore prescribe medication to lower blood pressure. But the patient himself is also responsible for preventive measures. Moderate alcohol consumption, abstaining from nicotine, daily exercise and a balanced diet reduce the risk of developing the disease.

Here’s what you can do yourself

A sudden brain hemorrhage is an acute emergency. With certain symptoms such as hemiplegia, speech disturbance, dizziness, the affected person must receive professional care as quickly as possible. These warning signs should be taken seriously and the emergency number 112 should be dialed immediately. Risk factors that can cause a brain hemorrhage can be prevented. One of the most common causes of cerebral hemorrhage is high blood pressure. To prevent hypertension, some measures should be followed. It is important for patients with high blood pressure to take their own blood pressure measurements every day, to visit their doctor regularly and to take the prescribed medication consistently. In this way, the risk of post-operative bleeding or rebleeding can be reduced. A regular health check is strongly advised in case of family history of stroke, heart attack, hypertension, impaired blood clotting and other metabolic disorders. Excessive consumption of alcohol and regular tobacco smoking endanger health. It has been proven that there is a two- to threefold increased risk. If possible, those affected should avoid excessive alcohol consumption altogether and stop smoking. Preventive measures should not only be started in old age. Those who pay attention to their lifestyle at an early stage can prevent a stroke. A balanced, vitamin-rich, low-fat, high-fiber diet (fresh fruits and vegetables) and exercise, among other things, support weight reduction (even a few pounds less body weight can prevent many health problems). Relaxation exercises such as yoga or autogenic training contribute significantly to maintaining good health.