Intracerebral Hemorrhage (ICH) Signs, Symptoms and Diagnosis

An intracerebral hemorrhage (ICH) is a condition where bleeding occurs in the tissue or ventricles of the brain. Its onset is usually sudden and catastrophic, but at times can present with milder symptoms resembling an ischemic stroke.

A hemorrhage deprives the brain of oxygen while putting pressure on the tissues nearby. The pooled blood which occurs inside the brain is called a hematoma. A hemorrhage can cause rapid brain damage or death.

Symptoms of ICH can vary depending on the location of the bleeding, how severe it is, and how much tissue is affected. Some common symptoms include:

1. Sudden tingling, weakness, numbness or paralysis, especially on one side of the body
2. Headache
3. Difficulty swallowing
4. Vision problems
5. Loss of coordination
6. Slurred speech
7. Difficulty understanding, reading, or writing
8. Loss of consciousness
9. Vomiting
10. Delirium
11. Seizures

Clinical Presentation

Patients with ICH can present with sudden neurologic deficits. When the hemorrhage is located in the posterior fossa, brainstem deficits may be observed, such as conjugate eye deviation, ophthalmoplegia, stertorous breathing, pinpoint pupils, or coma. When located in the hemispheres of the brain, a large hemorrhage can cause hemiparesis (weakness or inability to move on one side of the body).

Approximately half of the patients with major cases of ICH die within a few days. Of those who survive, the degree of remaining neurologic deficit will depend on the extent of healing as excess blood in the brain tissue is reabsorbed.

Laboratory Studies

When a patient presents with symptoms of ICH, the first tests they are likely to receive are laboratory studies. Those include:

1. Complete blood count (CBC) with platelets to check for infection, and to identify risk factors and complications
2. Prothrombin time (PT) or activated partial thromboplastin time to diagnose a coagulopathy
3. Serum chemistry with electrolytes and osmolarity to diagnose metabolic problems like hyponatremia
4. Toxicology for blood alcohol level, illicit drug use, and exogenous toxins that can cause ICH
5. Specific tests for less common causes of ICH like infections and hematologic disorders

Imaging Studies

Imaging studies will usually be carried out quickly in any patient suspected of having an ICH. A CT scan will identify acute hemorrhage as a very dense signal. Patients receiving anticoagulant or antiplatelet therapy who have had a mild blunt trauma need an immediate CT scan to rule out an ICH.

MRI is another common imaging technology used to diagnose ICH.

Lumbar Puncture

Lumbar puncture can detect ICH through a yellow discoloration showing that bilirubin is present in the spinal fluid or through biochemical changes.

Diagnosis

ICH can resemble ischemic stroke and some other conditions. In addition to laboratory and imaging tests, a thorough history and physical exam are carried out. Symptoms that occur suddenly, with neurologic deficit, altered consciousness, coma, or seizures are more likely to be caused by hemorrhagic stroke than ischemic stroke. Any history of trauma could be indicative of ischemic stroke.

Some other conditions that can cause symptoms similar to ICH are hyponatremia/hypernatremia, migraine, cancer, encephalitis, meningitis, subarachnoid hemorrhage, subdural hematoma, labyrinthitis ossificans, and hypertensive emergencies.