Acute Intracerebral Hemorrhage: A Life-Threatening Emergency in the Brain

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 Acute Intracerebral Hemorrhage: A Life-Threatening Emergency in the Brain

Dr. SB Lee, PhD (Medicine & Engineering)
Biomedical Scientist | Radiology & AI Imaging Specialist

What Is Acute Intracerebral Hemorrhage (AICH)?

Acute intracerebral hemorrhage (AICH) is a critical neurologic emergency that occurs when a blood vessel ruptures within the brain parenchyma, causing sudden bleeding. Unlike ischemic strokes, which are caused by blocked vessels, AICH involves spontaneous bleeding into brain tissue, often with devastating consequences.

AICH represents about 10–15% of all strokes, but its mortality and disability rates are significantly higher than those of ischemic stroke. Without urgent diagnosis and intervention, it can rapidly lead to coma or death.

Causes and Pathophysiology of AICH

 Common Causes

  • Chronic hypertension (most common)

  • Arteriovenous malformations (AVM) or cerebral aneurysms

  • Anticoagulant use (e.g., warfarin, DOACs)

  • Hemorrhagic tumors or metastases

  • Hematologic disorders such as thrombocytopenia

Pathophysiology

When a blood vessel ruptures:

  • High-pressure arterial blood enters the brain parenchyma.

  • A rapidly enlarging hematoma causes elevated intracranial pressure (ICP).

  • Surrounding brain tissue suffers from mass effect, ischemia, and edema.

  • If the brainstem is involved, vital functions like respiration and consciousness may be compromised.

Epidemiology: Who’s at Risk?

  • Incidence: ~24.6 per 100,000 people per year

  • Age: Mostly affects individuals over 60 years old

  • Sex: Slightly more common in males

  • Hypertension: Over 70% of AICH patients have a history of high blood pressure

Clinical Presentation: Recognizing the Symptoms

  • Sudden severe headache

  • Nausea and vomiting

  • Altered consciousness, from confusion to coma

  • Unilateral weakness or paralysis

  • Speech difficulties (aphasia or dysarthria)

  • Visual disturbances

  • Seizures

  • Ataxia or balance issues (especially in cerebellar hemorrhage)

Diagnosis: Imaging Is Key

1. CT Scan (Computed Tomography)


  • Gold standard for initial evaluation

  • Detects hyperdense hematoma in typical locations such as:

    • Pons

    • Thalamus

    • Putamen

  • Assesses ventricular compression or hydrocephalus

2. MRI (Magnetic Resonance Imaging)


  • Helps distinguish microbleeds and underlying lesions

  • SWI (Susceptibility Weighted Imaging) is highly sensitive

3. CTA / MRA (Angiography)


  • Evaluates for vascular malformations or aneurysms

Treatment Options

Conservative Management

  • Tight blood pressure control (Target SBP <140–160 mmHg)

  • ICP management using mannitol or hypertonic saline

  • Reversal of anticoagulation

  • Seizure prophylaxis if needed

Surgical Interventions

  • Surgical hematoma evacuation (for large, superficial, or cerebellar bleeds)

  • External ventricular drainage in cases of intraventricular hemorrhage (IVH)

  • Minimally invasive stereotactic evacuation (MIS) for select cases

Prognosis: High Risk, High Stakes

  • Mortality: 30–50% within 30 days

  • Poor prognostic factors:

    • Brainstem hemorrhage

    • Hematoma >30 mL

    • Depressed level of consciousness

    • Advanced age

  • Many survivors have permanent neurologic deficits, requiring early rehabilitation to maximize functional recovery.

Clinical Case Highlight


Patient: 53-year-old male

Findings: Irregular high-density lesion in the dorsal pons with compression of the fourth ventricle
Diagnosis: Acute pontine hemorrhage
Interpretation: This classic presentation illustrates how rapid CT imaging can identify life-threatening hemorrhage and inform immediate management.

Final Thoughts

Acute intracerebral hemorrhage is a true neurological emergency. Time is brain — and in AICH, minutes can mean the difference between life and death. Prevention (especially of hypertension), public awareness, prompt imaging, and rapid intervention are the keys to reducing mortality and improving outcomes.

For clinicians, radiologists, and emergency responders, recognizing the signs and acting fast is not just critical — it is life-saving.

References 

  1. Qureshi AI, Tuhrim S, Broderick JP, et al. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344(19):1450-1460.

  2. Hemphill JC et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015;46(7):2032–2060.

  3. An SJ, Kim TJ, Yoon BW. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage. J Stroke. 2017;19(1):3–10.

  4. Shoamanesh A et al. Prognosis in intracerebral hemorrhage. Lancet Neurol. 2017;16(10):791–800.

  5. Anderson CS et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

  6. Keep RF et al. Intracerebral hemorrhage: mechanisms of secondary brain injury. Stroke. 2012;43(6):1711–1717.

  7. Naidech AM et al. Anticoagulant-associated intracerebral hemorrhage. Nat Rev Neurol. 2014;10(7):410–418.

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