Intracerebral Hemorrhage

An intracerebral hemorrhage (ICH) is the term used for a bleed in the brain. It may be a distinct blood clot that displaces the brain surrounding it, or it may represent bleeding throughout an area of brain tissue itself.

An ICH may be large and life-threatening, or it may be small with milder symptoms. It can occur anywhere in the brain. There may also be hemorrhage into the cerebral ventricles , which is called an intraventricular hemorrhage.

Signs and Symptoms

Symptoms of ICH usually begin abruptly and may worsen over several hours. They may commonly include:

  • Headache
  • Weakness, tingling, or paralysis typically on one side of the body
  • Difficulty swallowing
  • Confusion
  • Trouble with vision
  • Difficulty with balance
  • Trouble speaking or issues with reading, writing or understanding speech
  • Changes in alertness or consciousness

Potential Causes

Intracerebral hemorrhage can occur as a result of several different conditions including:

  • High blood pressure This the most common cause of ICH. They typically occur deep in the brain or cerebellum. They are also called hypertensive hemorrhages. They result from bleeding from the very small arteries in the brain.
  • Bleeding disorder A problem with blood clotting is referred to as a coagulopathy. It can result from an inherited or acquired disorder that affects the blood clotting mechanisms. It may also be due to medications.
  • Underlying problems
    • Amyloid angiopathy (cerebral) In this condition, a protein called amyloid is deposited in the walls of blood vessels in the brain. It typically occurs in older patients and is commonly associated with dementia. ICHs can occur over time in different locations in the brain.
    • Ruptured brain aneurysm Although subarachnoid hemorrhage in the spinal fluid space is more commonly seen with a ruptured aneurysm, there can also be hemorrhage into the brain substance itself.
    • Ruptured brain AVM This is the most common cause of an ICH in children. It is one of the more common ways an AVM may present in an adult.
    • Tumor Occasionally, a primary or secondary (metastatic) brain tumor may bleed.
    • Head trauma This can result in an ICH or brain contusion (a bruise within the brain).


Diagnosis starts with the medical history and neurological examination. Tests commonly used to establish the diagnosis include: computed tomography ( CT ) scan, magnetic resonance imaging ( MRI ) scan, CT angiography ( CTA ) or cerebral angiography .

Treatment Options

Treatment options are based on several factors including:

  • Size and location of the ICH
  • Symptoms related to the ICH (mild symptoms vs. life-threatening)
  • Presence of an underlying cause
  • Patient age and condition
  • The goals associated with treatment

The medical and surgical treatment of ICH frequently undergoes evaluation, looking for ways to achieve better outcomes for the patient. The types of treatment and management of an ICH may include:

  • Observation This is typically used for smaller or deep ICHs. Medical issues such as blood pressure management and correction of bleeding issues are also addressed.
  • Open surgery (craniotomy) This option is typically considered for removal of a large, life-threatening ICH. It may also be used for treatment of an underlying cause such as a ruptured aneurysm, AVM or tumor.
  • Cerebral embolization This may be used in selected circumstances to treat an underlying cause when the ICH is not large enough to require removal. This typically involves treatment of an aneurysm or AVM.
  • Minimally invasive craniotomy In some circumstances, this may be considered for evacuation (removal) of an ICH located deep in the brain.
  • Decompressive craniectomy This surgery may be considered to reduce pressure related to an ICH. It may be used to relieve elevated ICP from an ischemic stroke that has bled (hemorrhagic conversion), where evacuation would require the removal of bloody brain tissue.
  • Ventriculostomy This is most often used to decrease pressure related to an intraventricular hemorrhage. Sometimes, medications may be injected through the external ventricular drain to help dissolve the clot. It may also be used to check the ICP.
  • ICP monitor This device may be used occasionally, but not routinely, in the course of management of an ICH.

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