What Is a Brain Bleed?

Bleeding in the brain, also called a brain hemorrhage, is a medical emergency caused by the rupture of an artery or vein due to abnormal pressure, trauma, and defect in the blood vessel. A brain bleed may be the result of high blood pressure, a brain tumor, a brain aneurysm, and other things.

A brain bleed is the second most common cause of stroke next to blood vessel obstruction (cerebral ischemia). Symptoms include head pain, vision changes, and weakness on one side of the body. A brain bleed is diagnosed with imaging tests and may require surgery to stop the bleeding and relieve pressure on the brain.

This article describes the symptoms and causes of a brain bleed, including how a hemorrhage in the brain is diagnosed and treated.

Type of Brain Bleeds

A brain bleed (hemorrhage) can involve any artery or vein in the brain. Arteries are the blood vessels that bring oxygen and nutrients to tissues, while veins take carbon dioxide and waste from tissues to be eliminated. Depending on the size and location of the blood vessel, a brain bleed can range in severity from mild to life-threatening.

Brain bleeds can be described in different ways based on their location and characteristics:

Intracerebral Hemorrhage

Intracerebral hemorrhage is a subtype of stroke that results from bleeding within the structure of the brain itself. It is characterized by bleeding that causes the formation of a blood pocket (called a hematoma).

There are two broad categories of hemorrhage:

• Intraparenchymal hemorrhage: This is a type of intracerebral hemorrhage that occurs within the functional tissues (parenchyma) of the brain.
• Intraventricular hemorrhage: This is a type of intracerebral hemorrhage that occurs in the brain’s ventricles, which are the cavities where cerebrospinal fluid (CSF) is produced.
  

Intracranial Hemorrhage

Intracranial hemorrhage is a general term that describes bleeding anywhere between the brain and the skull. The formation of a hematoma here places extreme external pressure on the brain.

There are four main types of intracranial hemorrhages:

• Subarachnoid hemorrhage: This is a type of intracranial hemorrhage that occurs between the innermost membrane of the brain (called the pia) and the adjacent middle layer (called the arachnoid mater)
• Subdural hematoma: This is a type of intracranial hemorrhage that occurs between the arachnoid mater and the outermost membrane covering the brain (called the dura mater).
• Extradural hemorrhage: This is a type of intracranial hemorrhage that occurs between the skull and dura mater.
• Epidural hematoma: This is a type of intracranial hemorrhage that involves the major veins or arteries serving all three membrane layers (known collectively as the meninges). These hemorrhages are typically caused by a blunt blow or penetrating injury to the skull.
  

Brain Bleed Symptoms

Brain bleed symptoms are caused by pressure exerted on brain tissues and/or damage caused to brain tissues as a result of the bleeding. Many of these symptoms are caused by the swelling of the brain, known as cerebral edema.

Symptoms may include:

• Head pain
• Neck or back pain
• Neck stiffness
• Vision changes
• Extreme sensitivity to light
• Weakness on one side of the face or body
• Slurred speech
• Lethargy
• Nausea and vomiting
• Confusion
• Behavioral changes
• Seizures
• Collapsing
• Loss of consciousness

A brain bleed may cause symptoms that rapidly worsen over the course of hours or days. Typically, the effects of a brain bleed are severe. However, many symptoms are non-specific and may not be immediately recognized as a brain problem until other, more obvious signs develop.

Complications

A brain bleed may cause permanent damage to the affected regions of the brain, resulting in:

• Permanent paralysis of part of the body (typically one-side)
• Speech impairment
• Loss of cognitive abilities
• Recurrent seizures (epilepsy)

In some instances, a midline shift of the brain will be identified. This is a dangerous situation in which the brain is actually shifted to one side, causing further compression on the brain.

Causes

All blood vessels can bleed, but bleeding of arteries or veins in the brain is uncommon. If it occurs, there is usually a precipitating factor.

Common causes of brain bleeds include:

• Head trauma: A head injury caused by a fall, vehicle accident, or any other blow to the head usually causes bleeding between the skull and surrounding membranes, resulting in an extradural, subdural, or subarachnoid hemorrhage.
• Ruptured aneurysm: An aneurysm is the bulging of an artery that can cause it to burst. Hypertension (high blood pressure) is the most common cause of a rupture. Even heavy lifting or straining can cause pressure within the brain to rise enough to trigger an eruption.
• Hemorrhagic conversion: An ischemic stroke is a type of stroke caused by the obstruction of a blood vessel in the brain. The ensuing pressure can sometimes cause the vessel to burst, causing bleeding referred to as hemorrhagic conversion.
  
• Brain tumor: Cancerous and non-cancerous tumors can cause bleeding by placing pressure on adjacent blood vessels as they grow, gradually weakening them and causing them to burst.
• Arteriovenous malformation: These are defects in the connection between arteries and veins that cause them to weaken, leak, and sometimes burst.
• Cerebral amyloid angiopathy: This is the build-up of proteins within the walls of arteries in the brain that can cause them to weaken, leak, and rupture.

Risk Factors

There are several risk factors for brain bleeds, including:

• Being over 75
• Uncontrolled hypertension
• Recreational stimulant drug use, such as methamphetamine or cocaine
• Bleeding disorders
• Medications that interfere with blood clotting, such as Plavix (clopidogrel)

These risk factors can make you more likely to experience a brain bleed after head trauma.

Diagnosis

Imaging tests are the primary tools for the diagnosis of a brain bleed. They can identify the location and size of a bleed as well as blood clots and obstructions inside a blood vessel.

Brain bleeds are typically diagnosed with a computed tomography (CT) scan. A CT scan is a technology that composites multiple X-rays to create a three-dimensional image of the brain.

In emergency situations, CT scans are generally more sensitive to acute bleeds than magnetic resonance imaging (MRI). With that said, MRIs (which create detailed images of soft tissues using magnetic and radio waves) are better able to detect smaller bleeds than a CT scan can sometimes miss.

Additional Testing

Other tests can help characterize the cause and nature of the bleed and direct the appropriate course of treatment.

These include:

• Cerebral angiogram: An angiogram is a type of CT or MRI scan that looks at blood vessels after injecting a contrast dye into a vein. A cerebral angiogram can identify a brain aneurysm that has ruptured or is on the verge of rupturing.
• Lumbar puncture Also called a spinal tap, this involves the extraction of cerebrospinal fluid from a space in the spinal column. It can help measure intracranial pressure, evaluate brain inflammation, and detect blood, infection, or cancer cells in the extracted fluid.
• Electroencephalogram (EEG): An EEG measures brain electrical activity to monitor for seizures and other adverse changes in the brain following a brain bleed. It is especially valuable for persons who are unconscious or in a coma.

Treatment

There are several treatment strategies for managing a brain bleed and preventing complications. Emergency surgery may be needed. Medical care may continue for weeks after treatment.

In some cases, no treatment may be needed if a bleed is small and non-progressive. But close monitoring is necessary should the bleeding suddenly restart.

Often, rehabilitation is necessary after recovery from a brain bleed.

Surgery

Surgery is often needed for brain bleeds, particularly in emergency situations. Prior to surgery, intravenous (IV) steroids may be used to reduce swelling in the brain.

Each type of brain bleed may require a specific surgical procedure:

• Hematomas: A large extradural or subdural hematoma may need to be surgically drained to reduce pressure and the risk of brain damage.
• Brain tumor: A brain tumor resection (removal) is a delicate procedure performed by a skilled neurosurgeon. If there are multiple tumors or a tumor is inoperable due to its location, radiation may be used to shrink the tumor instead.
• Brain aneurysm: An aneurysm is typically repaired with surgical clipping. This involves the placement of a tiny metal clip below the neck of the aneurysm to keep blood from flowing into it.
• Cerebral edema: Decompressive hemicraniectomy is the temporary removal of a portion of the skull to relieve the pressure caused by brain swelling.

Medications

In addition to surgical interventions, medical management is necessary. You may need IV fluids to prevent worsening edema. Intravenous steroids are often needed to reduce inflammation and edema. Anticonvulsant drugs may also be necessary to control seizures.

Rehabilitation

After the immediate treatment of a brain bleed, you may need physical therapy or speech therapy. Often, people recovering from a brain bleed need assistive care. You may need to re-learn things such as how to eat, speak, or walk.

If the bleed was severe, recovery can take up to a year, and many people only experience partial recovery. Rehabilitation following a brain bleed is similar to the process used for an ischemic stroke.

Summary

Bleeding in the brain is a serious medical emergency that can lead to disability or death. If you suspect a brain bleed, call for emergency help. Symptoms can be non-specific and may include head pain, neck pain, visual changes, weakness, slurred speech, lethargy, confusion, seizures, vomiting, and collapsing.

Brain bleeding can be caused by head trauma from a fall or accident. It can also be caused by a stroke, brain aneurysm, brain tumor, or rarely, spontaneous bleeding. Healthcare providers usually diagnose brain bleeding with imaging tests, including a CT scan or an MRI.

Treatment depends on the size and location of the brain bleed. Urgent surgery may be needed to remove a large subdural hematoma, brain tumor, or part of the skull to relieve pressure on the brain. Rehabilitation may be needed to help you relearn how to do things like eat, walk, or talk.