Brain Bleed, Hemorrhage (Intracranial Hemorrhage)

Overview

What is a brain bleed?

To most people, a “brain bleed” simply means any bleed inside your head. However, a doctor – and specifically doctors who treats brain bleeds (neurologists and neurosurgeons) – would say that a “brain bleed” (also known by the medical term intracranial hemorrhage) is too broad of a term. These doctors further describe brain bleeds by their exact location.

To better understand brain bleeds, it’s important to have a basic understanding of the different types. First, there are two main areas where bleeding can occur – bleeding can occur either within the skull but outside of the brain tissue, or inside the brain tissue. These areas are further divided as follows:

Bleeding within the skull but outside of the brain tissue

The brain has three membranes layers (called meninges) that lay between the bony skull and the actual brain tissue. The purpose of the meninges is to cover and protect the brain. Bleeding can occur anywhere between these three membranes. The three membranes are called the dura mater, arachnoid, and pia mater.

  • Epidural bleed (hemorrhage): This bleed happens between the skull bone and the utermost membrane layer, the dura mater.
  • Subdural bleed (hemorrhage): This bleed happens between the dura mater and the arachnoid membrane.
  • Subarachnoid bleed (hemorrhage): This bleed happens between the arachnoid membrane and the pia mater.

A view of the inner head showing the area -- the meninges -- between the skull and brain tissue. Brain bleeds can occur in the meninges layers, which are dura mater, arachnoid and subarachnoid space.

Brain bleeds can occur within the meninges, which is the area inside the skull but outside the actual brain tissue.

Bleeding inside the brain tissue

Two types of brain bleeds can occur inside the brain tissue itself – intracerebral hemorrhage (also called cerebral hemorrhage and hemorrhagic stroke) and intraventicular hemorrhage.

  • Intracerebral hemorrhage: This bleeding occurs in the lobes, pons and cerebellum of the brain (bleeding anywhere within the brain tissue itself including the brainstem).
  • Intraventricular hemorrhage: This bleeding occurs in the brain’s ventricles, which are specific areas of the brain (cavities) where cerebrospinal fluid is produced.

Epidural bleed, subdural bleed and subarachnoid bleed are brain bleeds outside of the actual brain tissue. Intraventricular hemorrhage and intracerebral hemorrhage are bleeds that occur inside the brain tissue.

Brain bleeds can occur in the meninges layers outside the brain tissue or inside the brain tissue itself.

What happens to the brain when there is bleeding inside the head?

Since the brain cannot store oxygen, it relies upon a series of blood vessels to supply oxygen and nutrients. When a brain hemorrhage occurs, oxygen may no longer be able to reach the brain tissue supplied by these leaky or burst vessels. Pooling of blood from an intracranial hemorrhage or cerebral hemorrhage also puts pressure on the brain and deprives it of oxygen.

When a hemorrhage interrupts blood flow around or inside the brain, depriving it of oxygen for more than three or four minutes, the brain cells die. The affected nerve cells and the related functions they control are damaged as well.

Are brain bleeds fatal?

Brain bleeds, regardless of location, usually happen suddenly. (However, some – for example, subdural hematomas – can take days to weeks before symptoms develop.) A brain bleed causes brain damage and yes, they can be life-threatening. The seriousness and outcome of a brain bleed depends on its cause, location inside the skull, size of the bleed, the amount of time that passes between the bleed and treatment, your age and overall health. Once brain cells die, they do not regenerate. Damage can be severe and result in physical, mental, and task-based disability.

Who is affected by brain bleeds (intracranial hemorrhage)?

Various types of intracranial hemorrhages strike people of all ages. Although cerebral hemorrhage (bleeding anywhere inside the brain tissue itself) and hemorrhagic stroke (specifically, when a blood vessel breaks and bleeds into the brain) are most commonly associated with older adults, they can also occur in children (pediatric stroke).

A few stats

  • Cerebral hemorrhage accounts for about 13% of all strokes in the United States. It is the second leading cause of stroke. (The leading cause of stroke is a blood clot – thrombus – in an artery in the brain, which blocks the flow of blood and cuts off needed oxygen and nutrients to the brain.)
  • Ruptured brain aneurysms affect about 30,000 people in the United States each year.
  • Arteriovenous malformations (AVM) are present in about 1% of the population, and about 2% of all hemorrhagic strokes are from an AVM each year.

Symptoms and Causes

What are the causes of brain bleeds (intracranial hemorrhage)?

Bleeding in the brain has a number of causes, including:

  • Head trauma, caused by a fall, car accident, sports accident or other type of blow to the head.
  • High blood pressure (hypertension), which can damage the blood vessel walls and cause the blood vessel to leak or burst.
  • Buildup of fatty deposits in the arteries (atherosclerosis).
  • Blood clot that formed in the brain or traveled to the brain from another part of the body, which damaged the artery and caused it to leak.
  • Ruptured cerebral aneurysm (a weak spot in a blood vessel wall that balloons out and bursts).
  • Buildup of amyloid protein within the artery walls of the brain (cerebral amyloid angiopathy).
  • A leak from abnormally formed connections between arteries and veins (arteriovenous malformation).
  • Bleeding disorders or treatment with anticoagulant therapy (blood thinners).
  • Brain tumor that presses on brain tissue causing bleeding.
  • Smoking, heavy alcohol use, or use of illegal drugs such as cocaine.
  • Conditions related to pregnancy or childbirth, including eclampsia, postpartum vasculopathy, or neonatal intraventricular hemorrhage.
  • Conditions related to abnormal collagen formation in the blood vessel walls that can cause to walls to be weak, resulting in a rupture of the vessel wall.

What are the symptoms of brain bleeds (intracranial hemorrhage)?

Symptoms of a brain hemorrhage depend on the area of the brain involved. In general, symptoms of brain bleeds can include:

  • Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body.
  • Headache. (Sudden, severe “thunderclap” headache occurs with subarachnoid hemorrhage.)
  • Nausea and vomiting.
  • Confusion.
  • Dizziness.
  • Seizures.
  • Difficulty swallowing.
  • Loss of vision or difficulty seeing.
  • Loss of balance or coordination.
  • Stiff neck and sensitivity to light.
  • Abnormal or slurred speech.
  • Difficulty reading, writing or understanding speech.
  • Change in level of consciousness or alertness, lack of energy, sleepiness or coma.
  • Trouble breathing and abnormal heart rate (if bleed is located in brainstem).

Diagnosis and Tests

How are brain bleeds (intracranial hemorrhage) diagnosed?

A doctor will examine you immediately if any type of brain hemorrhage is suspected. Diagnosis is usually made based on the results of:

  • An evaluation of your physical symptoms.
  • Computed tomography (CT) scan, magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) of your brain. These imaging tests determine the location, extent and sometimes the cause of the bleed.

Other tests may include:

Management and Treatment

How are brain hemorrhages treated?

Any type of bleeding inside the skull or brain is a medical emergency. If you or a loved one have experienced a blow to the head or have symptoms that may indicate a brain bleed, call 911. It is important to get to a hospital emergency room immediately to determine the cause of the bleeding and to begin medical treatment.

If a stroke has occurred, the cause (bleeding or blood clot) must be determined so that the appropriate treatment can be started. Prompt medical treatment can help limit damage to the brain, which will improve your chance of recovery.

Surgery may be needed in the following situations:

  • Bleeding (hemorrhage) may require immediate decompression of the brain to release pooled blood and relieve pressure. Decompression may be done through a burr hole procedure (drilling a hole in the skull to allow blood drainage), a craniectomy incision (partial removal of the skull to allow the swelling brain to expand), or a craniotomy (opening of the skull cavity).
  • A cerebral aneurysm that has not ruptured may require clipping or filling (“sealing off”) of the aneurysm through a craniotomy surgical procedure, or an angiography-type procedure to prevent a future rupture.
  • An arteriovenous malformation (AVM) that has not ruptured is treated by direct removal of the AVM through surgery, use of computer-guided radiation to close off the abnormal vessels or use of a special glue or other filler to block the blood flow from smaller blood vessels into the AVM or the vessels that supply the AVM.
  • Some brain hemorrhages do not require surgery. The decision depends on the size, cause and location of the bleed and other factors.

Other treatments may include:

  • Anti-anxiety drugs and/or medication to control blood pressure.
  • Anti-epileptic drugs for seizure control.
  • Other medications needed to control other symptoms, such as painkillers for severe headache and stool softeners to prevent constipation and straining during bowel movements.
  • Nutrients and fluids as needed. These may be given through a vein (intravenously), or a feeding tube in the stomach (gastronomy tube), especially if the patient has difficulty swallowing.

What does rehabilitation after a brain bleed entail?

The goals of long-term treatment are to help you regain the functions needed for daily living, as much and as soon as possible, and to prevent future brain hemorrhages. Rehabilitation and recovery time vary according to each person’s unique brain bleed and the extent of rehabilitation possible.

Long-term rehabilitation treatment may include:

  • Physical therapy.
  • Speech therapy or alternative forms of communication.
  • Occupational therapy.
  • Changing lifestyle habits to reduce risk of another hemorrhage. (See next question.)

Prevention

Is there anything I can do to reduce my risk of a brain bleed?

Steps you can take to reduce your risk include:

Outlook / Prognosis

What recovery can I expect after a brain hemorrhage?

Besides depriving the brain of oxygen and killing brain cells, bleeding inside the brain also prevents nerve cells from communicating with the parts of the body and the functions they control. This results in a loss of memory, speech or movement in the affected area.

Depending on the location of the hemorrhage, the extent of damage and your age and overall health, there can be lasting effects from a brain bleed. These affects can include:

  • Inability to move part of the body (paralysis).
  • Numbness or weakness in part of the body.
  • Difficulty swallowing.
  • Vision loss.
  • Difficulty speaking or understanding spoken or written words.
  • Confusion, memory loss or poor judgment.
  • Personality change and/or emotional problems.
  • Seizures.
  • Headaches.

However, over time and with a lot of effort and determination in rehabilitation (physical, occupational and speech therapy), you can regain some of these lost functions. This is especially true if your general health is otherwise good.

Unfortunately, some patients who remain in a coma, or have been severely paralyzed after an intracranial or cerebral hemorrhage may need permanent, long-term care typically provided in a nursing home. Depending on the type, location and extent of the brain bleed, many patients do not survive the initial bleeding event.

Remember though, if you suspect a brain bleed, the sooner you can get to the emergency room the better your chance of survival. Time between the start of symptoms and start of a bleed and between start of a bleed and confirmation of a bleed are critical time points. The earlier a brain hemorrhage is found, the earlier a treatment decision can be made. Don’t hesitate. Let a healthcare professional determine if you have a brain emergency.

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