Lobar intracerebral hemorrhage

Definition

Lobar intracerebral hemorrhage is bleeding in the largest part of the brain called the cerebrum.

Alternative Names

Hemorrhage - intraparenchymal; Hemorrhage - intracerebral (lobar)

Causes, incidence, and risk factors

Lobar intracerebral hemorrhage (ICH) may be caused by:

• Angioma, a type of blood vessel tumor
• Bleeding into a tumor
• Blood clotting problems
• Blood vessel problems such as aneurysm or arteriovenous malformation
• Head injury (trauma)

In some cases, no cause can be found.

When it is not caused by trauma, lobar ICH is considered a type of hemorrhagic stroke, the most serious type of stroke.

Lobar ICH is associated with the apolipoprotein (apo) E gene, which is linked to an increased risk for Alzheimer's disease.

Lobar hemorrhages are also associated with the following:

• Cerebral amyloid
  • Decreased levels of blood platelets
  • High blood pressure
  • Liver disease (associated with increased bleeding risk)
  • Some autoimmune disorders
• Use of aspirin or blood thinners
• Various blood or bleeding disorders such as disseminated intravascular coagulation, hemophilia, sickle cell anemia, and leukemia

Symptoms

Symptoms usually develop suddenly without warning, often during activity. The symptoms vary, depending on the location of the bleeding and the amount of brain tissue affected.

A change in alertness or level of consciousness is the first symptom in half of patientsn. The person may seem:

• Apathetic, withdrawn
• Sleepy, lethargic, stuporous
• Unconscious, comatose

Dementia occurs before the bleed occurs in those with cerebral amyloid. This condition is rare in children.

Other symptoms may include:

• Abnormal sensations
• Clumsiness
• Difficulty moving any body part
• Difficulty speaking or understanding speech
• Difficulty swallowing
• Difficulty writing or reading
• Eyelid drooping
• Facial paralysis
• Headache
  • May develop suddenly
  • May wake you up from sleep
  • Gets worse when you change position, bending, strain, or cough
• Loss of all or part of vision
• Loss of balance
• Loss of coordination
• Loss of muscle function or feeling
• Movement changes
• Neck or shoulder ache
• Neck pain (when bending neck)
• Seizure
• Sensation changes
  • Decreased sensation
  • Numbness or tingling
  • Weakness of any body part
• Stiff neck
• Vomiting
  • Occurs frequently, usually more often in the morning
  • Often described as occurring without nausea

Signs and tests

A neurological exam may show signs of increased intracranial pressure or decreased brain functions. Your specific symptoms can help reveal which part of the brain is affected. Some patients with mild hemorrhages may only have a headache.

An eye exam may show changes in eye movement, abnormal reflexes, and swelling of the optic nerve from increased pressure in the brain.

Tests may include:

• Angiography of the head -- may be necessary to determine if there is an aneurysm or arteriovenous malformation
• CBC
• Bleeding time
• Liver function tests
• Kidney function tests
• Head CT -- may be preferred if bleed is less than 48 hours old
• MRI of head
• Platelet count
• Prothrombin time (PT) or partial thromboplastin time (PTT)

Treatment

The treatment depends on the specific location, severity, and cause of the bleeding. Treatment may include a lifesaving measure called medical hyperventilation, which involves inserting a breathing tube and forcing the person to breathe rapidly. This reduces pressure in the brain.

Surgery may be needed in some cases to repair or remove structures causing the bleed (such as a cerebral aneurysm or arteriovenous malformation).

Medicines may be prescribed to control pain, reduce swelling, and control seizures. If a bleeding disorder is present, medications or blood products may also be given.

Expectations (prognosis)

How well a patient does depends on the amount of swelling and how much blood collects in the brain.

Recovery may occur completely, or there may be some permanent loss of brain function. Death is possible, and may quickly occur despite prompt medical treatment.

Medications, surgery, or other treatments may have severe side effects.

Complications

Complications will vary depending on the extent of damage and the location of the bleed.

In general, blood irritates the tissues of the brain and may cause swelling (cerebral edema). Blood collects into a mass (hematoma). These complications put increasing pressure on the brain and can destroy brain tissue. Blood can also irritate the delicate tissues covering the brain. This is called meningeal irritation.

Complications may include:

• Complications of surgery
• Hydrocephalus (fluid build-up the brain)
• Permanent loss of any brain function
• Seizure disorder
• Side effects of medications used to treat the disorder

Calling your health care provider

Go to the emergency room or call 911 if symptoms of a brain hemorrhage occur.

Any type of intracerebral hemorrhage is a severe condition requiring prompt medical attention. It may develop quickly into a life-threatening situation.

Emergency symptoms include difficulty breathing, seizures, loss of ability to move or swallow, sudden loss of sensations, sudden change in mental state, and loss of consciousness.

Prevention

Treatment and controlling any risk-related disorders may reduce the risk of developing a brain hemorrhage.

High blood pressure should be treated as appropriate. Do not stop taking prescription medications unless advised to do so by your health care provider. Abruptly stopping such medications could lead to this disorder.

If you take blood thinners such as Coumadin, your health care provider will order regular blood tests to make sure your medication dosage isn't raising your risk for a hemorrhage.

References

Zivin JA. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 432.

Goldstein LB. Prevention and management of stroke. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders;2007:chap 58.