Intracranial hemorrhage is bleeding within the skull cavity (cranium) that usually progresses rapidly and often results in permanent brain damage and death. All bleeding within the skull is called intracranial bleeding, whether the bleeding occurs within the brain itself (intracerebral hemorrhage) or in the area between the brain and the skull (epidural, subdural, and subarachnoid hemorrhage).

A cerebral hemorrhage is an intra-axial hemorrhage; that is, it occurs within the brain tissue rather than outside of it. The other category of intracranial hemorrhage is extra-axial hemorrhage, such as epidural, subdural, and subarachnoid hematomas, which all occur within the skull but outside of the brain tissue. There are two main kinds of intra-axial hemorrhages: intraparenchymal hemorrhage and intraventricular hemorrhages. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious medical emergency because they can increase intracranial pressure, which if left untreated can lead to coma and death. The mortality rate for intraparenchymal bleeds is over 40%.

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.

Predilection sites for intracerebral hemorrhage include the basal ganglia (40-50%), lobar regions (20-50%), thalamus (10-15%), pons (5-12%), cerebellum (5-10%), and other brainstem sites (1-5%).

High blood pressure, atherosclerosis (buildup of plaque in artery walls), and amyloid angiopathy (protein deposits in artery walls) can weaken blood vessel walls. Aneurysms, which are bulges in weakened areas, can form when blood vessels are damaged or they can be present at birth. Arteriovenous malformations, which are abnormal connections between arteries and veins that may be present at birth, are another vascular abnormality that can be a site of cerebral hemorrhage.

The most common cause of a brain hemorrhage is elevated blood pressure. Over time, elevated blood pressure can weaken arterial walls and lead to rupture. When this occurs, blood collects in the brain leading to symptoms of a stroke. Other causes of hemorrhage include aneurysm — a weak spot in the wall of an artery — which then balloons out and may break open. Arteriovenous malformations (AVM) are abnormal connections between arteries and veins and are usually present from birth and can cause brain hemorrhage later in life. In some cases, people with cancer who develop distant spread of their original cancer to their brain (metastatic disease) can develop brain hemorrhages in the areas of brain where the cancer has spread. In elderly individuals, amyloid protein deposits along the blood vessels can cause the vessel wall to weaken leading to a hemorrhagic stroke. Cocaine or drug abuse can weaken blood vessels and lead to bleeding in the brain. Some prescription drugs can also increase the risk of brain hemorrhage.

There are several risk factors and causes of Intracerebral Hemorrhage. The most common include:

●High blood pressure. This chronic condition can, over a long period of time, weaken blood vessel walls. Untreated high blood pressure is a major preventable cause of brain hemorrhages.

●Head trauma. Injury is the most common cause of bleeding in the brain for those younger than age 50.

●Aneurysm. This is a weakening in a blood vessel wall that swells. It can burst and bleed into the brain, leading to a stroke.

●Blood vessel abnormalities. (Arteriovenous malformations) Weaknesses in the blood vessels in and around the brain may be present at birth and diagnosed only if symptoms develop.

●Amyloid angiopathy. This is an abnormality of the blood vessel walls that sometimes occurs with aging and high blood pressure. It may cause many small, unnoticed bleeds before causing a large one.

●Blood or bleeding disorders. Hemophilia and sickle cell anemia can both contribute to decreased levels of blood platelets.

●Liver disease. This condition is associated with increased bleeding in general.

●Brain tumors.

●Controlling your blood pressure

●Eating a healthy diet

●Exercising regularly

●Quitting smoking

●Taking precautions against falling

●Using safety devices such as helmets and seatbelts when necessary

Symptoms of cerebral hemorrhage are related to their location. Some can interfere with function of parts of the body, some can interfere with sensation, and some can interfere with thought processes.

Although headache is frequently associated with bleeding in the brain, it is not always present. Most often, the symptoms associated with a brain hemorrhage are dependent on the particular area of the brain that is involved. If the bleeding is in the part of the brain associated with vision, there may be problems seeing. Problems with balance and coordination, weakness on one side, numbness, or sudden seizure may occur. The speech center for many people is located in the left side of the brain and bleeding into this area may cause marked speech disturbances. If the bleeding is in the lower brain (brainstem), where most of the automatic body functions are regulated, a patient may become unresponsive or go into a coma. Additionally, sometimes symptoms of brain hemorrhage may come on very abruptly and rapidly worsen. Alternatively, the symptoms may progress slowly over many hours or even days.

●Change in level of consciousness or alertness such as passing out or unresponsiveness

●Difficulty swallowing

●Difficulty with thinking, talking, comprehension, writing or reading

●Loss of vision or changes in vision

●Numbness or weakness

●Paralysis

●Seizures

●Severe headache

●Change in level of consciousness or alertness such as passing out or unresponsiveness

●Change in mental status or sudden behavior change such as confusion, delirium, lethargy, hallucinations or delusions

●Garbled or slurred speech or inability to speak

●Paralysis or inability to move a body part

●Seizure

●Sudden change in vision, loss of vision, or eye pain

●Trauma to the head

●Worst headache of your life

The individual with an intracranial hemorrhage is often unconscious or dazed or otherwise unable to give a complete medical history. The physician may need to rely on those who were with the individual when the event occurred, as well as friends or family members, to provide information about the individual's current and past medical conditions and diseases. In this case, the history may be inaccurate or incomplete for past injuries, illnesses, surgical procedures, and current treatment of existing chronic diseases. Individuals with intracerebral hemorrhage may have a history of hypertension, diabetes, or treatment with anticoagulants. Symptoms of hemorrhage typically come on during the day and include progressive deterioration in consciousness (50% of cases), nausea and vomiting (40% to 50% of cases), headache (40% of cases), seizures (6% to 7% of cases), weakness or paralysis on one side (including face, arm, and leg), slurred speech, difficulty expressing themselves in words (expressive aphasia) or understanding speech (receptive aphasia), disturbances in eye movement, difficulty swallowing (dysphagia), or respiratory depression.

The examiner may observe changes in the individual's mental status and level of consciousness that may range from clouding of consciousness, confusion, lethargy, obtundation, and stupor to coma. Strength testing may reveal weakness or paralysis on one side. The individual may vomit and have seizures. Speech may be disturbed. Elevated pressure inside the cranium (intracranial pressure [ICP]), and thus in the brain and CSF, may result in pupils that appear unequal in size and react sluggishly to light. If the individual's neurological status is deteriorating rapidly, the examiner must make a quick diagnosis of the type of trauma or hemorrhage based on the most prominent signs and symptoms, so surgical intervention can proceed.

Computed tomography (CT) is the standard diagnostic tool to quickly determine the presence of skull fractures and bleeding within the skull. If the CT is negative for bleeding, lumbar puncture is performed to determine if blood is present in the CSF. Magnetic resonance imaging (MRI) is not used in the acute phase of injury but is useful after the initial 48 hours to assess the extent of injury to the brain. If a ruptured aneurysm is suspected, a complete vascular study (arteriography) of the carotid and cerebral arteries helps pinpoint the location of the ruptured aneurysm. An angiography may also be performed if subarachnoid hemorrhage is suspected. Additional diagnostic tests may include an electrocardiogram (ECG), chest X-ray, urinalysis, and blood studies (complete blood count [CBC], prothrombin time [PT], erythrocyte sedimentation rate [ESR], blood glucose, electrolytes, and blood type). A diagnosis of subdural hemorrhage/hematoma may require additional tests because symptoms are similar to those of many other diseases and conditions.

Immediate medical treatment for acute intracranial hemorrhages includes maintaining the airway; assisting respiration if needed; regulating body temperature, blood oxygen level, and blood pressure; establishing intravenous (IV) access to replace fluids and maintain a constant blood sugar level; controlling external bleeding; monitoring ICP; and stabilizing the cervical spine until cervical fracture is ruled out. Maintaining an acceptable ICP with corticosteroids and diuretics is mandatory so that further brain injury does not occur. Setting respiratory parameters so that breaths occur frequently and deeply (hyperventilation) decreases carbon dioxide levels, which lowers intracranial pressure. Once the individual's condition stabilizes, treatment focuses on maintaining the status quo and treating underlying medical conditions and diseases.

●Antihypertensive therapy in acute phases. The AHA/ASA and EUSI guidelines (American Heart Association/American Stroke Association guidelines and the European Stroke Initiative guidelines) have recommended antihypertensive therapy to stabilize the mean arterial pressure at 110 mmHg. One paper showed the efficacy of this antihypertensive therapy without worsening outcome in patients of hypertensive intracerebral hemorrhage within 3 hours onset.

●Giving Factor VIIa within 4 hours limits the bleeding and formation of a hematoma. However, it also increases the risk of thromboembolism.

●Mannitol is effective in acutely reducing raised intracranial pressure.

●Acetaminophen may be needed to avoid hyperthermia, and to relieve headache.

●Frozen plasma, vitamin K, protamine, or platelet transfusions are given in case of a coagulopathy.

●Fosphenytoin or other anticonvulsant is given in case of seizures or lobar hemorrhage.

●H2 antagonists or proton pump inhibitors are commonly given for stress ulcer prophylaxis, a condition somehow linked with ICH.

●Corticosteroids, in concert with antihypertensives, reduces swelling.

●Surgery is required if the hematoma is greater than 3 cm (1 in), if there is a structural vascular lesion or lobar hemorrhage in a young patient.

●A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures.

●Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited.

●Tracheal intubation is indicated in patients with decreased level of consciousness or other risk of airway obstruction.

●IV fluids (Intravenous therapy) are given to maintain fluid balance, using normotonic rather than hypotonic fluids.

aneurysm ['ænjʊriz(ə)m] n.动脉瘤

arteriography [ɑː,tiəri'ɒgrəf] n.动脉造影

atherosclerosis [,æθərəʊskliə'rəʊsis; -sklə-] n.动脉粥样硬化

coagulopathy [kəu,ægju'lɔpəθi] n.凝血障碍

consciousness ['kɒnʃəsnis] n.意识

corticosteroids [,kɔːtikəus'tirɔid] n.皮质激素，类固醇

electrocardiogram [i,lektrəʊ'kɑːdiəgræm] n.心电图

lethargy ['leθədʒi] n.昏睡，嗜睡

mannitol ['mænitɒl] n.甘露醇

numbness ['nʌmnəs] n.麻木，麻痹

seizures ['siːʒə] n.癫痫发作

subarachnoid [,sʌbə'ræknɔid] adj.蛛网膜下的

thalamus ['θæləməs] n.丘脑

thromboembolism [,θrɒmbəʊ'embəliz(ə)m] n.血栓栓塞

amyloid angiopathy 淀粉样脑血管病

arteriovenous malformations 动静脉畸形

basal ganglia 基底节

difficulty swallowing 吞咽困难

extra-axial hemorrhage 额外轴向出血

hemorrhagic stroke 出血性卒中

high blood pressure 高血压

intracranial pressure 颅内压

intraparenchymal hemorrhage 脑实质内出血

intraventricular hemorrhages 脑室出血

mortality rate 死亡率

respiratory depression 呼吸抑制