Cerebral Haemorrhage

A cerebral haemorrhage is bleeding between the skull and brain tissue. It is a life-threatening type of stroke that occurs when a weakened blood vessel in the brain leaks or bursts. Immediate medical attention is crucial, as the condition can lead to permanent brain damage or death if not treated quickly.

Table of contents

• What is a Cerebral Haemorrhage?
• Types of Brain Bleeds
• Causes and Risk Factors
• Warning Signs and Symptoms
• Diagnosis
• Treatment Options
• Outlook and Recovery
• Prevention

What is a Cerebral Haemorrhage?

A cerebral haemorrhage, also known as an intracranial hemorrhage (a term that describes any bleeding inside the skull), is a type of stroke that causes bleeding in your head^[1]. When a brain bleed occurs, a blood vessel leaks blood or bursts. Blood collects or pools within your skull and brain. This causes pressure against your brain, which prevents oxygen and nutrients from reaching your brain tissues and cells^[1].

Your brain cannot store oxygen, so it relies on a series of blood vessels to supply its oxygen and nutrients. When blood begins leaking out of a vessel, it can irritate the surrounding brain tissue and cause swelling, known as cerebral edema (swelling of the brain). The pooled blood collects into a mass called a hematoma (a collection of blood outside blood vessels)^[4].

Cerebral haemorrhages account for about 13% of all strokes and are the second most common cause of stroke^[3][4]. Brain bleeds can be life-threatening and cause permanent brain damage^[1]. The severity and outcome depend on the cause, location inside of your skull, size of the bleed, and the amount of time that passes between the bleed and treatment. It only takes three to four minutes for your brain cells to die if they don’t receive enough oxygen^[1].

cerebral hemorrhage, intracranial hemorrhage, intracerebral hemorrhage, hemorrhagic stroke, brain bleed

Types of Brain Bleeds

There are many parts to your brain, so the term “brain bleed” is very broad. Types of brain bleeds help healthcare providers identify specifically where the bleeding occurs. There are two main areas of bleeding: within your skull but outside of brain tissue, and inside brain tissue^[1].

To better understand where each type of brain bleed occurs, it helps to know the components within your skull. The brain has three membrane layers called meninges (protective layers covering the brain) between the bony skull and brain tissue. The three membranes are the dura mater (outermost layer), arachnoid (middle layer), and pia mater (innermost layer). Bleeding can occur anywhere between these three membranes^[1].

Types of brain bleeds within your skull but outside of brain tissue include:

• Epidural bleed: This bleed happens between the skull bone and the outermost membrane layer, the dura mater. It is usually arterial or venous in origin and typically occurs after blunt trauma to the head, often involving a skull fracture that tears an underlying blood vessel^[1][5].
• Subdural bleed: This bleed happens between the dura mater and the arachnoid membrane. Subdural bleeds can be acute (developing quickly), subacute (taking days or weeks to develop after an injury), or chronic (happening slowly, often in older adults or people taking blood thinners)^[1][4].
• Subarachnoid bleed: This bleed happens between the arachnoid membrane and the pia mater. It usually happens because of head trauma or a ruptured brain aneurysm (a bulge in a blood vessel in the brain)^[1][6].

There are two types of brain bleeds that occur inside the brain tissue itself:

• Intracerebral hemorrhage: This bleeding occurs in the lobes, brainstem, and cerebellum of your brain. This is bleeding anywhere within the brain tissue itself and is the most common type of hemorrhagic stroke^[1][7].
• Intraventricular hemorrhage: This bleeding occurs in your brain’s ventricles, which are specific areas of the brain (cavities) where your body makes cerebrospinal fluid (fluid that protects your brain and spinal cord)^[1].

Causes and Risk Factors

A cerebral haemorrhage most commonly affects people who have a bulge in a blood vessel in their brain, called a brain aneurysm. There is not always an obvious reason why you may have a brain aneurysm. Some people have them from birth, while others may get them later^[15].

There are several causes of bleeding inside the skull, including:

• Head injuries: For people under the age of 50, this is the most common cause of haemorrhage inside the skull. In the elderly, subdural hematoma after relatively minor head injury is not uncommon^[6].
• Hypertension (chronic high blood pressure): Poorly controlled high blood pressure over a long period of time causes changes to the arteries of the brain which can make them much more likely to rupture. Hypertension is one of the leading causes of brain haemorrhage^[9][6].
• Arteriovenous malformation (AVM): This is an anatomical abnormality in the arteries or veins in or around the brain. Such an abnormality may be present from birth, but it is only detected if symptoms develop. When an AVM occurs, a tangle of blood vessels in the brain bypasses normal brain tissue and directly diverts blood from the arteries to the veins^[6][7].
• Aneurysm: This is a weakening in a blood vessel wall that swells. The thin walls of an aneurysm can burst and cause bleeding into the subarachnoid space and the brain, leading to haemorrhagic stroke^[6].
• Amyloid angiopathy: This is an abnormality in the blood vessel walls. It occurs with increasing frequency with aging. It may cause many small, asymptomatic haemorrhages prior to causing a large symptomatic one^[6].
• Brain tumors: Hemorrhagic stroke may occur on the background of brain tumors^[3].
• Use of blood thinners: These medications increase the risk of bleeding^[9].

Additional risk factors include:

• Age: more common after age 55^[9]
• Gender: more common in men^[9]
• Race: affects African Americans and Asians more than whites, likely related to higher prevalence of hypertension in those races^[9]
• Previous history of stroke^[9]
• Alcohol use and street drugs: cocaine and amphetamines increase risk^[9]
• Liver disease: increases risk due to issues with blood clotting^[9]
• Diabetes, high cholesterol, low cholesterol^[3]
• Smoking^[6]

Warning Signs and Symptoms

Symptoms of a brain bleed vary based on the type, but symptoms can appear or worsen suddenly and progress over minutes to hours^[1][9]. The symptoms of bleeding inside the skull tend to come on rapidly and include:

• Sudden, severe headache that starts suddenly and does not go away (called a “thunderclap headache”)^[1][15]
• Sudden tingling, weakness, numbness, or paralysis of your face, arm, or leg, particularly on one side of your body^[1][2]
• Nausea and vomiting^[1][2]
• Confusion^[1]
• Dizziness or feeling lightheaded^[3]
• Slurred speech or difficulty speaking^[1]
• Vision or hearing problems^[3]
• Seizures (fits) or shaking uncontrollably^[15]
• Decreased level of consciousness or total loss of consciousness^[3]
• Neck pain or a stiff neck^[15]
• Being very sensitive to light^[15]
• Fainting, feeling sleepy (drowsy), or being confused^[15]
• Drooping on one side of your face^[15]

A subarachnoid haemorrhage can happen at any time, but it may be more likely when you’re doing something like coughing, going to the toilet, lifting something heavy, or having sex^[15].

If you or someone you’re with experiences these symptoms, call emergency services immediately (999 or 911). A brain bleed is a life-threatening medical emergency and requires quick treatment for the best outcome^[1][2].

Diagnosis

On the basis of symptoms, doctors may strongly suspect bleeding inside the skull. A non-contrast computerized tomography (CT) scan (an imaging test that uses X-rays to create detailed pictures) of the brain is the diagnostic study of choice^[9][6]. CT scans are the most commonly used imaging scan to diagnose intracranial hematomas^[1].

If the CT scan does not confirm the diagnosis, a lumbar puncture (spinal tap) can be used to confirm or rule out subarachnoid haemorrhage. A lumbar puncture may also be needed if infection of the brain or its covering layers is suspected^[6].

Additional diagnostic tests may include:

• MRI scan (magnetic resonance imaging): This test uses magnetic fields and radio waves to make computerized images^[1].
• CT or MR angiogram: This is recommended once the patient is stabilized to look at the blood vessels^[9].
• Angiogram: If there is concern about a possible aneurysm in the brain or other blood vessel issue, an angiogram can provide more information. This test uses X-rays and a special dye to produce pictures of the blood flow in the blood vessels in the brain^[1].
• Blood work, urinalysis, vascular study, and electroencephalogram may also be ordered^[2].

Treatment Options

Treatment of cerebral haemorrhage focuses on stopping the bleeding, removing the clot, and relieving pressure on the brain. Any type of brain bleed is considered a medical emergency, and patients must receive immediate care to determine the appropriate treatment and to have the best chance at a full recovery^[2].

Management begins with stabilization of vital signs. Perform endotracheal intubation for patients with a decreased level of consciousness and poor airway protection^[12]. Treatment should typically be carried out in an intensive care unit^[3].

Medical Management

In some cases, medication may be used to control conditions, such as:

• Blood pressure control: Antihypertensive agents to reduce blood pressure and other risk factors of heart disease^[12]
• Seizure prevention: Anticonvulsants to prevent seizure recurrence. Patients with clinical seizures should immediately receive a benzodiazepine, such as lorazepam or diazepam, for rapid seizure control^[12]
• Intracranial pressure control: Osmotic diuretics such as mannitol to decrease intracranial pressure^[12]
• Reversal of anticoagulation: If you take blood-thinning medicine, you may need therapy to reverse the effects of the medicine. This will reduce the risk of further bleeding. Options include giving vitamin K^[13]
• Antacids to prevent associated gastric ulcers^[12]

Glucose levels should be monitored, with normoglycemia (normal blood sugar levels) recommended^[12].

Surgical Treatment

The main treatment for certain types of cerebral haemorrhage is surgery to stop the bleeding. This may be done by:

• Removing a small piece of bone from the skull, using a tiny metal clip to seal the burst blood vessel (aneurysm), and then replacing the bone—called neurosurgical clipping^[15]
• Putting a thin, flexible tube into an artery in your groin or leg, guiding it to where the burst blood vessel is, and passing tiny metal coils up the tube into the aneurysm to block it—called endovascular coiling^[15]
• A haemorrhage may require a surgeon to put a small hole in the skull or to otherwise open the skull to relieve pressure^[2]
• A procedure to place an external ventricular drain may be used to treat hydrocephalus (accumulation of fluid due to blood or brain swelling blocking natural drainage pathways) or increased intracranial pressure^[3][9]

Evacuation of hematoma, either via open craniotomy or endoscopy, may be a promising ultra-early-stage treatment for intracerebral haemorrhage that may improve long-term prognosis^[12]. Immediate neurosurgical consultation is strongly advised for all cases of haemorrhage, especially when alarming signs such as airway compromise, respiratory failure, or hemodynamic instability are evident^[5].

Candidates for non-surgical treatment are patients with minimal symptoms, minimal chance of a favorable outcome (large haemorrhage, poor neurologic condition, advanced age, bleeding disorder), or a haemorrhage location where surgery would cause more harm^[9].

Outlook and Recovery

Cerebral haemorrhage has the highest mortality rate of all stroke subtypes. Greater than one-third of patients with intracerebral haemorrhage will not survive, and only 20 percent of patients will regain functional independence^[10][3]. Studies indicate that 44% die within one month^[3].

Brain bleeds can be life-threatening and cause permanent brain damage. The severity and outcome of a brain bleed depend on its cause, location inside of your skull, size of the bleed, and the amount of time that passes between the bleed and treatment. Once brain cells die, they don’t come back. Damage can be severe and result in physical, mental, and task-based disability^[1].

Recovery Stages

How a cerebral haemorrhage affects your life varies from person to person and depends on where in the brain the bleeding happened and the amount of damage it has caused. Although it can take months or years to get better, most people improve with treatment, and some recover fully^[15].

Recovery generally progresses through the following phases:

• Acute recovery: This phase, which typically lasts for the first few days after the event, focuses on stabilizing the patient’s condition using medical interventions such as surgery, medication, and monitoring in ICU or stroke units^[16].
• Rehabilitation phase: Once the patient is stable, the focus shifts to rehabilitation, which includes physical therapy, occupational therapy, and speech therapy. These therapies aim to help the patient regain movement, speech, cognitive abilities, and independence in daily life. Starting rehabilitation early—within the first 90 days, often referred to as the “golden window”—is critical for optimal outcomes^[16][19].
• Long-term recovery: This phase is all about preventing relapse and promoting overall well-being. It includes routine follow-ups, healthy lifestyle practices, and mental health support^[16].

Potential Complications and Effects

You may experience:

• Seizures (fits)^[15]
• Heart, lung, or liver problems^[15]
• Cognitive difficulties, such as problems with memory, concentration, and communication^[15]
• Depression and mood changes^[15]
• Feeling restless and extremely tired (fatigue)^[15]
• Headaches and unusual feelings^[15]
• Physical effects including weakness, numbness, or paralysis^[15]

A small number of people develop epilepsy after having a cerebral haemorrhage^[15].

You will have regular follow-ups with your doctor and recovery team. They will talk with you about any possible complications and whether you need any further tests or treatment. They may want to check for any problems in your blood vessels, manage other brain aneurysms, or treat a build-up of fluid around your brain (hydrocephalus)^[15].

Long-term rehabilitation or long-term care may be needed in some cases^[2]. Emotional recovery is as vital as physical. Consider therapy, join a support group, or practice mindfulness to manage stress, anxiety, or depression^[19].

Prevention

While some risk factors for brain haemorrhage, such as age and genetics, are beyond our control, there are steps we can take to reduce the risk and protect our brain health:

• Manage high blood pressure: Keeping your blood pressure under control through lifestyle changes, such as maintaining a healthy diet, exercising regularly, and managing stress, can significantly reduce your risk. Keep blood pressure ideally below 130/80 mm Hg^[18][19].
• Avoid smoking and excessive alcohol consumption: Both smoking and heavy alcohol consumption can increase the risk of brain haemorrhage by damaging blood vessels and raising blood pressure. Quitting smoking and moderating alcohol intake can help protect your brain health^[18].
• Maintain a healthy diet: Eating a balanced diet rich in fruits, vegetables, whole grains, and lean proteins can support overall health and reduce the risk of conditions like obesity, diabetes, and high cholesterol, which are associated with an increased risk of brain haemorrhage. Include foods rich in omega-3 fatty acids, antioxidants, and B vitamins^[18][19].
• Exercise regularly: Regular physical activity is essential for maintaining cardiovascular health and reducing the risk of conditions like obesity and high blood pressure. Aim for at least 30 minutes of moderate-intensity exercise most days of the week^[18].
• Manage diabetes: Keep blood sugar levels under control^[19].
• Reduce cholesterol: Manage cholesterol levels through diet, exercise, and medication if prescribed^[19].
• Take prescribed medications on time: Follow your doctor’s instructions carefully^[19].
• Get regular check-ups: Regular visits to your healthcare provider can help monitor your overall health and identify any underlying conditions or risk factors for brain haemorrhage^[18].
• Manage stress: Chronic stress can take a toll on both your physical and mental health, increasing the risk of conditions like high blood pressure and cardiovascular disease. Find healthy ways to manage stress, such as meditation, yoga, or spending time with loved ones^[18].
• Be mindful of head trauma: Head injuries, such as concussions, can increase the risk of brain haemorrhage, especially if they occur repeatedly. Take precautions to prevent head injuries, such as wearing protective gear during sports and avoiding risky activities^[18].

Educate yourself about the signs and symptoms of brain haemorrhage and seek immediate medical attention if you experience any warning signs^[18].