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Intracerebral Haematoma

What is an intracerebral haematoma (ICH)?

An intracerebral haemorrhage (ICH) is a serious condition caused when a blood vessel within the brain bleeds leaking blood into the brain tissue. It is also known as a haemorrhagic stroke. When there is bleeding within the brain, oxygen is deprived to an area of the brain which can cause swelling and pressure within the brain.

diagram of Intracerebral Haematoma

The symptoms include:

  • Sudden onset of headache often with nausea and vomiting
  • Drowsiness and difficulty in responding
  • Stroke like symptoms such as a weakness on one side of the face and or body
  • Problems with speech and/or swallowing
  • Problems with or loss of vision
  • Dizziness and loss of balance
  • Confusion or disorientation
  • Seizures (fits)

 

What causes an ICH?

There are many causes for an ICH including:

  • High blood pressure which can causes a build-up of pressure within tiny arteries deep within the brain causing them to burst
  • Blood thinning medication for example warfarin, dabigatran or rivaroxaban which are used to prevent clots forming in the body.
  • A burst brain aneurysm (a defect in the wall of the blood vessel)
  • Arteriovenous malformation (AVM), which is a tangle of abnormal blood vessels
  • Head trauma
  • Bleeding disorders such as thrombocytopaenia, haemophilia or sickle cell disease
  • Underlying brain tumours including vascular tumours known as angioma’s
  • Cerebral Amyloid Angiopathy, which is an abnormal build-up of protein in the blood vessels of the brain making them leaky and susceptible to bleeding
  • Over-use of alcohol
  • Smoking
  • Diabetes
  • Drug use such as cocaine, amphetamines or other illicit drugs
  • Spontaneous or unknown cause

 

This booklet isn’t for you if you have an underlying cause such as an aneurysm, AVM or tumour. There is separate information and support which goes into more specific detail for these conditions.

 

Who is affected?

ICH is more common in men than women Advancing age and hypertension are risk factors for spontaneous ICH

How is an ICH diagnosed?

In most cases, a CT scan of your head will confirm a diagnosis of ICH. This is a scan that uses Xrays and a computer to create detailed pictures of your brain.

Following that you will be transferred to the Walton centre for consideration of further specialist tests to diagnose a possible underlying cause for the bleed:

CT angiogram: A CT scan that is taken following an injection of contrast into a vein in your arm. A computer is used to make up detailed pictures of the blood vessels in your brain in order to diagnose an underlying vascular abnormality.

Angiogram: An angiogram is a thin tube that is inserted into an artery in the groin. This is passed through the blood vessels to the brain. Dye is then injected, and X-ray pictures are taken. This will provide detailed images of the blood vessels in the brain and will be considered if there is a suspicion that there may be an underlying vascular abnormality that has caused the bleed.

Angiogram:

Magnetic Resonance Imaging (MRI scan): An MRI scan uses magnets and radio waves to show very clear pictures of the brain.

It is used to help diagnose other underlying causes, for example a stroke due to lack of blood flow to an area of the brain, or more rarely, certain vascular malformations or tumours. It will also detail the severity of the haemorrhage and its effect on your brain and helps understand how it has affected you for long term planning of your care.

Treatment

Treatment depends on the underlying cause and how well you are. Some bleeds don’t need treatment: you will simply need management of any risk factors that may have contributed.

Medical treatment

If safe to do so, the haemorrhage will be left alone to reabsorb naturally. This will be the case if it is small and effects are minimal. The effects of blood thinners will be reversed using drugs.

You will be monitored closely on the intensive care or a specialist ward

Blood pressure will be controlled using medication or infusions if necessary

Pain will be controlled using medications

Other risk factors such as diabetes will be monitored and controlled

Blood tests are taken to analyse your treatment or look for rare causes

Your care will be managed by the expert neurosurgical or neuromedical teams (sometimes both oversee care during your inpatient stay)

Specialist management will be tailored according to the underlying cause

Please be aware that the effects of the bleed on your brain are likely to fluctuate. Symptoms may even get worse before they stabilise and improve. This is because of the toxic effects on the brain of blood breaking down.

If there is any concern, then you will have a CT scan to check on the situation and your management may change as a result. This may include the consideration of surgery.

Brain surgery

If the clot is causing serious symptoms, emergency surgery is necessary to remove the clot and relieve the effects of the pressure on the brain. This is normally the case for large haemorrhages or those that are close to important structures of the brain such as the brain stem.

Surgery includes cutting a hole in the skull using specialist equipment to expose the brain and allow a neurosurgeon to remove the clot. If the brain is very swollen, the skull may be left off in order to give it room to swell and allow the brain to heal:- This is generally a life-saving measure.

External Ventricular Drain:

In some cases, an external ventricular drain (EVD) is needed. This is a temporary thin plastic tube which is inserted to drain the fluid within the brain (cerebro-spinal fluid). This is necessary if there is a blockage to the drainage of the fluid because of the position of the bleed or to keep pressure in the brain down.

Intensive care

It is sometimes necessary to have a stay in the Intensive Care Unit for specialist management and close monitoring to help lessen both the effects of pressure and blood toxins on the brain which can be life threatening.

If the effects of the haemorrhage are serious, or there is deterioration in symptoms it will be necessary to rest the brain and control the pressure within the skull by placing a patient into induced coma, where breathing is supported by a ventilator.

The pressure in the brain (intracranial pressure or ICP) may be monitored through a bolt attached through the skull. This helps the intensive care staff take measures to reduce the ICP. It also allows the doctors and nurses to recognise improvement before waking from the coma.

Intensive care stay may be for a number of weeks but once stable the team will prepare transfer to the wards for ongoing care and rehabilitation.

Feeding will be made possible by use of a tube from the nose to the stomach, where liquid food is used to maintain nutrition (NG tube)

Hydration will be maintained though fluids in the vein or through the NG tube.

Recovery

Recovery is dependent on the size and position of the bleed, the underlying cause, the treatment you receive as well as your health and well-being prior to becoming ill. Recovery follows a variable path and is specific to each person. You will have good days and bad days for a period of time. Complications such as infection may delay or prolong your recovery

Complications:

Depending on the effects and location of the haemorrhage complications may include:

  • Loss or impaired movement on one side of the body
  • Loss or impaired sensation on one side of the body
  • Speech and language impairment
  • Extreme tiredness
  • Visual loss or problems such as double vision
  • Cognitive dysfunction (memory loss, difficulty reasoning), confusion
  • Memory impairment
  • Seizures
  • Low mood or depression

Rehabilitation

It is likely that you will need specialist rehabilitation. The extent of this will be dependent on your symptoms and how poorly you have been. This is specific to what is available in your local hospital or what the specialist team think will benefit you most. It includes medical input from a specialist in rehabilitation, physiotherapy, occupational therapy, speech and language therapy, dietetic review of your nutrition and psychology.

It may include

? Specialist inpatient rehabilitation

? Referral back to the hospital you came from for specialist stroke rehabilitation

? Inpatient therapy in the Walton Centre and discharge home with the support of a local outpatient specialist rehabilitation team if needed.

Ongoing management:

If no underlying abnormality that can be treated is found, you can reduce your chances of ICH by:

  • Not smoking
  • Keeping blood pressure controlled
  • Keeping blood sugars controlled if you are diabetic
  • Not taking illicit drugs such as cocaine or amphetamines
  • Treating heart disease
  • Keeping cholesterol under control
  • Healthy diet
  • Gentle exercise as able
  • Keeping alcohol intake within government guidelines

 

Long term outlook

This varies from person to person and depends on your health prior to the ICH, your age, the cause and the extent of damage from the bleed. It also depends on your response to the treatment and rehabilitation you have received. Recovery can take months or years. Most people who suffer an intracerebral haemorrhage have long term effects which can vary from mild, to needing long term care in a specialist nursing home. Symptoms are specific to the individual. You may find that many symptoms are made worse if you are tired, under stress or ill. This is particularly so if you experience seizures, headaches or have been left with physical impairment as a result of the bleed.

Lifestyle is important when recovering. Lifestyle choices can make you feel worse or better. Gentle exercise as you are able, eating well and preventing dehydration all help symptom control. Getting the right amount of sleep helps; too much or too little sleep can make you feel worse. If you do too much, you may feel worse that evening or the next day. The general rule is if you want to do something and feel able to, then you can. If you find a lot of activity makes you exhausted or worsens your symptoms, then plan an easy day afterwards.

Memory problems

Memory problems are common in people who have had an ICH. You may be left with minor or big problems with your short-term memory, attention and concentration.

Visual problems

visual problems can occur. These can present as blurred, double, partial or very rarely, complete loss of vision and is often dependent on the position of the bleed. Assessment and help can be gained if you have visual problems through a specialist eye doctor called an ophthalmologist.

Extreme tiredness

You will probably need rest once you get home particularly if you are having a lot of visitors or your house is very busy. Even simple tasks such as a walk to the local shop may leave you feeling exhausted. This should improve with time but may go on especially if you have a severe impairment from the ICH. You will know if you have done too much as you will be exhausted and may experience more headaches. This often happens early evening or the next day and means you have to take a rest! Pacing activities as well as regular exercise will help.

Headaches

Headaches are common after ICH and usually they ease with time. They may, however, persist. Headaches can be triggered by dehydration, stress, illness, too much or too little sleep and missing meals. Prolonged or regular use of analgesia (paracetamol, ibuprofen, codeine, morphine etc.) may also worsen or prolong headaches so should be used sparingly and stopped if no longer required. Drinking 2 to 3 litres of water per day, regular meals, ensuring a good sleep pattern and in some instances avoidance of certain triggers (caffeine, alcohol, cheese etc.) can help reduce the frequency and severity of headaches. There are also some non-invasive treatment options such as menthol sticks to rub on the forehead which may help. Drinking more water and using pain relief at the start of a headache may also help. If headaches persist and are troublesome despite this, you may need specialist management.

Everyday activities

Driving

You must not drive and must inform the DVLA if you have been diagnosed with an intracerebral haemorrhage and are still having symptoms after a month. This is because driving involves many different cognitive and physical skills as well as multi-tasking, decision making and problem solving. You cannot drive if you have visual problems or ongoing stroke like symptom. You cannot drive if you have had seizures as a result of the ICH. You cannot drive if you are experiencing cognitive or ongoing physical problems as a result of the ICH.

Driving restrictions are enforced by the DVLA and each case has to be approved individually. You must speak to your medical team or nurse to clarify driving restrictions. You may be able to apply for a blue badge if you have been severely impaired as a result of the ICH. This will allow the car you travel in to park in specially designated disabled parking. Having a disability after an ICH does not always mean you will never be able to drive: You may be able to apply for specialist assessment to drive or be able to apply for an adapted car if you are cognitively recovered and have a limb weakness. More details can be found on the DVLA website.

Sport and swimming

Exercise is encouraged as it improves stamina and wellbeing. Most sports can be resumed once you feel able and any wounds have healed. You should build up your fitness slowly as you feel able. Extreme exercise and contact sports are normally avoided until your investigations are completed and you are feeling fully recovered. If you have had an operation on your brain, you should speak to your nurse or doctor about which exercises are safe and if you need any specialist protection for your head.

If you have seizures you may need to be careful about certain exercise such as swimming. Taking a companion and letting the lifeguard know is advisable if you have had seizures or for the first year after a bleed.

Flying

Flying is not advised in the first six weeks following surgery. You should inform your holiday insurance company that you have had an ICH. If you haven’t had any surgery there will still be restrictions with you flying until you are medically stable. Each case has to be assessed individually and so your medical team will advise this when you are in hospital.

Returning to work

This depends on the effects of the ICH and the type of job you do. Also, how you are and whether you need a car to work. Most people benefit from some time off to recover and look after themselves. It is advisable to go back to work on a phased return. The length of time you need to recover is dependent on what has happened and what treatment you have had. Your neurovascular nurses will advise you. You can get support returning to work from the citizens advice bureaux or the brain charity. They will advise you of any support, benefits or help you can get; for example “access to work”.

Washing and dying hair

You can wash your hair with mild shampoo, 3 days following surgery, but you cannot dye it until the wounds have fully healed.

Alcohol

It is best to limit alcohol and adhere to government guidelines. Excess alcohol increases blood pressure and puts strain on the heart, so is not advised. If you experience seizures, there is a risk of provoking one if you drink too much alcohol. If you are taking medication, you should check with your doctor if it is safe to drink alcohol with these.

Illicit drugs

We recommend that you do not use illicit drugs as some may increase blood pressure for long periods of time which may cause harm.

Sex

You can have sex as soon as you feel able.

 

  • Last Updated:
    01 December 2020
  • Review Date:
    01 December 2023
  • Author:
    C. Stoneley. Neurovascular ANP (Reviewed by Dr S McCrory)
  • Summary:

    An intracerebral haemorrhage (ICH) is a serious condition caused when a blood vessel within the brain bleeds leaking blood into the brain tissue. It is also known as a haemorrhagic stroke.

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