Intracerebral Hematoma
An intracerebral hematoma (ICH) is bleeding that develops within the brain tissue itself. It may be spontaneous (often due to high blood pressure) or traumatic; the spontaneous form is the most common type of hemorrhagic stroke. The bleeding directly damages brain tissue, creates a mass effect and raises intracranial pressure. It requires urgent diagnosis and appropriate management.
Останнє оновлення: 2026-06-07
Definition
An intracerebral hematoma is a collection of blood within the brain parenchyma (tissue). Spontaneous (non-traumatic) intracerebral hemorrhage is the most common form of hemorrhagic stroke and accounts for roughly 10-15% of all strokes. Bleeding within the brain is a serious condition because of direct tissue injury, edema in the surrounding tissue and raised intracranial pressure. A traumatic intracerebral hematoma develops in association with head trauma, frequently together with areas of contusion.
Causes and Risk Factors
The most common cause of spontaneous bleeding is chronic high blood pressure; these hemorrhages typically lie in deep regions such as the basal ganglia, thalamus, pons and cerebellum. In older age, deposition of amyloid in the brain's blood vessel walls (cerebral amyloid angiopathy) can lead to bleeding near the cortical surface (lobar). Other causes include vascular malformations (arteriovenous malformation, cavernoma), use of blood-thinning drugs, clotting disorders, certain recreational drugs and bleeding within a tumor. The traumatic form is related to direct head impact and contusion.
Symptoms
Symptoms vary with the location and size of the bleed. Common features are a sudden, severe headache, weakness or paralysis on one side of the body (hemiparesis/hemiplegia), sensory loss, speech disturbance (aphasia, dysarthria) and seizures. With large hemorrhages, consciousness becomes progressively impaired; vomiting, bradycardia and raised blood pressure indicate increased intracranial pressure. In brainstem or cerebellar hemorrhages, loss of consciousness, balance disturbance and breathing problems may predominate.
Diagnosis
An urgent non-contrast brain CT scan is the gold standard; fresh bleeding appears hyperdense (bright) and the hematoma volume can be calculated quickly. CT angiography may be used to screen for vascular malformations and to assess the risk of active bleeding (contrast leakage, the 'spot sign'). Magnetic resonance imaging (MRI) is valuable for investigating the cause of bleeding (vascular malformation, tumor, old microbleeds) and in the subacute phase. In young patients or where a vascular cause is suspected, digital subtraction angiography (DSA) may be performed. Laboratory tests are requested to assess the use of blood thinners and the clotting status.
Treatment Approach
The initial approach is to secure the airway, breathing and circulation. Controlled lowering of high blood pressure, reversal of the drug effect in patients on blood thinners, and management of intracranial pressure (head elevation, sedation, osmotic therapy) are key steps. Control of blood glucose and temperature, deep vein thrombosis prophylaxis and prevention of aspiration are part of intensive care management. Routine seizure prophylaxis is not recommended; antiepileptic treatment is used only if a clinical seizure occurs.
Surgical Treatment
The decision to operate is based on the location and size of the bleed and the patient's neurological status. For cerebellar hematomas, surgical evacuation is strongly recommended, particularly if the diameter is large or there is brainstem compression or hydrocephalus. For superficial (lobar) hematomas, surgery may be considered in selected cases. For deep-seated hematomas routine surgery is generally not recommended, although it may be considered in situations such as large volume and progressive deterioration. Where bleeding extends into the fluid-filled spaces of the brain (ventricles) and hydrocephalus is present, an external ventricular drain may be placed. Minimally invasive (stereotactic or endoscopic) evacuation techniques may be used in selected cases; the benefit of these options is still under investigation.
Course, Recovery and Prevention
Intracerebral hematoma is a high-risk type of stroke; the course is related to the volume and location of the bleed, the patient's age and the level of consciousness on presentation, and is assessed using tools such as the ICH score. Recovery is fastest in the first few months, and early rehabilitation (physiotherapy, speech therapy) is important. The most effective measure to reduce the risk of recurrence is strict blood pressure control; lifestyle adjustments and careful evaluation of blood-thinner use also contribute. Outcomes vary from patient to patient and no result can be guaranteed.
Джерела
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:1071-1076.
- Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke. 2022;53(7):e282-e361.
- Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897.
- Mendelow AD, Gregson BA, Rowan EN, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II). Lancet. 2013;382(9890):397-408.
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