Spontaneous intracranial hemorrhage

Disease Description (Causes and Symptoms)

• Definition summary: A condition in which a blood vessel spontaneously ruptures inside the brain or cranial cavity, causing bleeding into the brain parenchyma, subarachnoid space, ventricles, or other areas. This most often occurs when small cerebral blood vessels rupture due to long-standing hypertension.
• Main causes: Chronic hypertension (most common), cerebral amyloid deposition, arteriovenous malformation (AVM), cerebral aneurysm rupture (mainly subarachnoid hemorrhage), vasculitis, brain tumors, use of anticoagulants/antiplatelet agents, and unknown cause (idiopathic), among others.
• Pathophysiology summary: A hematoma forms following blood vessel rupture, causing local brain tissue compression, ischemia, and inflammation. Increased intracranial pressure and brain herniation due to the hematoma, as well as hydrocephalus caused by obstruction of the ventricles, may occur.
• Main symptoms: Sudden severe headache (especially with subarachnoid hemorrhage), vomiting, dizziness, decreased consciousness or stupor, focal neurological deficits (hemiplegia, decreased sensation, aphasia, etc.), and elevated blood pressure. Symptoms vary depending on the location and amount of bleeding.

Treatment Methods

• Initial emergency treatment (immediately after arrival at the hospital)
  • Secure the airway, breathing, and circulation (ABCs), and provide oxygen.
  • Perform prompt brain imaging (non-contrast CT) to confirm the hemorrhage and determine its location and size.
  • Blood pressure control: In the acute phase, rapid stabilization of blood pressure is important to prevent excessive rebleeding and cerebral edema. Many guidelines recommend lowering the target when systolic blood pressure is very high after symptom onset (for example, in the range of 150–220 mmHg), with the target individualized according to the situation.
  • Patients taking anticoagulants or antiplatelet agents: After confirming the medication history, reversal should be performed (vitamin K/PCC, idarucizumab, andexanet alfa, etc.).
  • If signs of increased intracranial pressure (ICP) are present: Position the head elevated 30 degrees, provide sedation and analgesia, use osmotherapy (mannitol or hypertonic saline), and, when necessary, perform endotracheal intubation and adjust mechanical ventilation.
• Imaging and vascular examinations
  • CT and MRI are used to evaluate the hematoma and cerebral edema, while cerebral angiography (CT/DSA) is useful for differentiating aneurysms and AVMs → Active testing is recommended for subarachnoid hemorrhage or atypical hemorrhage.
• Surgical treatment
  • Hematoma removal (craniotomy) or minimally invasive transcranial evacuation (using an endoscope or catheter insertion followed by thrombolytic administration/drainage): The decision depends on the hematoma’s location (close to the cortex, frontal lobe, temporal lobe, etc.), size, the patient’s level of consciousness, and other factors.
  • If hydrocephalus develops due to intraventricular hemorrhage, perform external ventricular drainage (external drainage catheter, EVD).
  • When an aneurysm is the cause of subarachnoid hemorrhage, perform aneurysm clipping or coil embolization.
  • For AVM hemorrhage, surgery, embolization, or Gamma Knife treatment is selected according to the patient’s condition and the AVM’s location.
• Medication treatment and intensive care
  • Control fluids, electrolytes, and blood glucose, and control body temperature (actively treat fever).
  • Treat seizures with anticonvulsants; routine long-term prophylactic anticonvulsant administration is not universally recommended (consider it in cases involving the cortex or with a history of seizures).
  • Prevention of thromboembolism: Initially start mechanical prevention (compression stockings), and after the hemorrhage has stabilized, consider adding medication such as low-dose low-molecular-weight heparin.
• Rehabilitation and long-term management
  • Begin early rehabilitation after the acute phase (including physical therapy, occupational therapy, and speech therapy).
  • Manage the underlying cause (hypertension, reassessment of the need for anticoagulants, treatment of vascular malformations, etc.) and take preventive measures.
• Summary of precautions
  • Any unsupervised discontinuation or resumption of anticoagulants or antiplatelet agents requires a specialist’s judgment.
  • Avoid excessive lowering of blood pressure, which can reduce cerebral perfusion — the target should be individualized according to the patient’s condition.
  • Monitor for complications such as infection, pulmonary embolism, myocardial infarction, and rebleeding.

Checklist Before an Outpatient Visit (Items to Prepare and Example Questions)

• Items to prepare (bring to the hospital)
  • A list of all medications currently being taken (including prescription drugs, OTC medications, and herbal medicines), along with the times taken and dosages.
  • Recent test results (CT/MRI image files or reports) and hospitalization records, if any.
  • Notes recording when the symptoms began and how they progressed (when they occurred, what symptoms appeared, and factors that improved or worsened them).
  • Existing underlying conditions (hypertension, diabetes, heart disease, bleeding tendencies, etc.) and a history of previous surgery or bleeding.
  • Contact information for a close caregiver and the patient’s level of daily functioning (such as whether they can live alone).
• Example questions to check before an outpatient visit
  • When did the symptoms last begin?
  • Are you currently taking anticoagulants, antiplatelet agents, or supplements (for example, thrombolytic agents or vitamin E)?
  • Have there been any recent changes in your blood pressure, blood glucose, or weight?
  • Do you have previous CT/MRI scans or records of surgery or procedures?

Examples of General Questions to Ask the Doctor

• What caused this condition, and what was the cause in my case?
• Is surgery necessary given my current condition? If so, what are the expected benefits and risks?
• What is the risk of recurrence after the acute phase, and what is the prognosis?
• Should I continue taking my current medications (for example, anticoagulants or antihypertensive medications)? If I need to stop them, when should I restart them?
• What rehabilitation plan and expected duration will help with recovery?
• What precautions should I take to prevent complications such as infection, blood clots, or seizures?

Examples of Condition-Specific Questions

• If I am taking an anticoagulant (for example, warfarin, dabigatran, or rivaroxaban), what reversal treatment is needed if bleeding occurs, and can it be provided immediately at the hospital?
• Based on the location and size of my hemorrhage, is surgery (hematoma removal or ventricular drainage) recommended, and what is the likelihood of neurological recovery expected after surgery?