Hemorrhage - causes, symptoms and therapy

Hemorrhage - causes, symptoms and therapy

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The general term brain hemorrhage actually includes different bleeding scenarios within the skull and, depending on the interpretation of the term, can refer to different areas of the skull. Often, the cerebral hemorrhage occurs as part of a stroke or a severe traumatic brain injury, in which blood vessels are injured. Brain hemorrhage is actually always dangerous, which is why you should never wait too long before starting therapy.


As the control center of the body, the brain (also: cerebrum or encephalon) has the most important task in the area of ​​body functions. The areas of the brain can be divided as follows:

  • Cerebrum (telencephalon) - the cerebrum is largely responsible for cognitive abilities such as memory and higher thinking processes.
  • Midbrain (diencephalon) - controls in particular the sensitive functions of the brain, including sensory perception, temperature regulation, nerve functions such as pain sensation and the sleep-wake rhythm. The hormone balance is also regulated by nerve impulses from the midbrain.
  • Cerebellum (cerebellum) - is responsible for the motor skills of the body, i.e. locomotion, coordination and the sense of balance. In addition, researchers assume that the cerebellum also plays a role in unconscious learning.
  • Brainstem (Truncus cerebri / Truncus encephali) - the brainstem forms the link between the brain and spinal cord. He is responsible for the processing of sensory impressions, but also for the transmission of motor impulses from the brain. Furthermore, the brain stem controls essential vital functions such as the heartbeat, breathing, eyelid, swallowing and coughing reflexes.

The sensitive areas of the brain are enclosed by the cranial bone. This is lined by the meninges, which protectively surround the brain and coarsely

  • the hard meninges (dura mater encephali),
  • the cobweb skin (Arachnoidea encephali),
  • and have the delicate meninges (pia mater encephali) divided.

Both the meninges and the brain itself are traversed by a large number of blood vessels, which makes the variants of cerebral hemorrhage extremely extensive. As the name already shows, bleeding occurs in the various structures of the brain. As a result, the affected areas of brain tissue are only insufficiently supplied with nutrients and oxygen, or are depressed by the amount of blood entering them. This can be fatal, because if parts of the brain remain without regulated nutrient and oxygen supply for a long time, they will eventually cease to function and, in the worst case, even die completely and irreparably. Depending on the location of the hemorrhage, a distinction is made between the following bleeding variants:

  • Extracerebral hemorrhage - "only" the meninges are affected by the bleeding,
  • Epidural hematoma - a special form of extracerebral hemorrhage that causes bleeding into the epidural space,
  • Subdural hematoma - a bruise under the hard meninges,
  • Subarachnoid hemorrhage - an extracerebral hemorrhage in the area of ​​the spider's skin,
  • intracerebral hemorrhage - there is actual bleeding in the brain.

Heart disease and vascular disease as the main cause

By far the most common cause of bleeding in the brain is hypertension. If left untreated, it leads to a loss of elasticity in the vessel walls - especially in the area of ​​the smallest blood vessels, such as those found in the brain. If there are now high blood pressure peaks, as is usual in the case of physical exertion, stress or a hypertensive crisis, the pressure-loaded blood vessels can no longer counteract this effect and tear, causing a cerebral hemorrhage.

Arteriosclerosis (arteriosclerosis) is based on a similar mechanism. As a result of a gradual calcification of the smallest blood vessels, there is a loss of stability and elasticity in the vessel walls, which leads to tearing of the blood vessel when the blood pressure peaks are high. Since hypertension and arteriosclerosis very often occur together, it is seldom possible to say exactly which mechanism ultimately led to bleeding in the brain.

Congenital or acquired vascular malformations of the blood vessels in the brain are also conceivable as the cause of the bleeding in the brain due to heart diseases and vascular diseases. Most malformations are innate in this regard and remain undetected for a long time because they rarely cause symptoms and therefore there is no reason to visit a doctor. Sometimes, however, the malformations become noticeable through recurrent headaches and migraine attacks or seizures and are then identified in the subsequent diagnosis. The most common vascular malformations include

  • Aneurysms,
  • Angiomas
  • and cavernomas.

There are a number of other vascular-related complaints that massively increase the risk of brain hemorrhage from vascular damage. For example, tumors or metastases in the brain can grow so unfavorably around blood vessels that there is a process of remodeling of the walls of the vessels, which can ultimately lead to bleeding in the brain. And alcohol and drug consumption, as well as the abuse of anabolic steroids, can massively increase the risk of brain bleeding due to vascular damage.

Warning: The consumption of these substances during pregnancy can also lead to an increased tendency of the unborn child to bleed!

Blood disorders and bleeding in the brain

Patients with an increased tendency to bleed are also at increased risk of having bleeding in the brain. Your blood lacks the factors necessary for blood clotting (hemotase), which are also referred to as FI to FXIII. With the exception of calcium ions (coagulation factor FVI), these are genetically pre-programmed proteins, the function of which can be considerably disturbed by harmful influences such as diseases or the effects of substances. As a result, the blood becomes extremely thin, which, in addition to increased wound bleeding, also leads to an increased escape of blood from the vessel walls.

Diseases with an increased tendency to bleed include hereditary genetic defects such as hemophilia. Thrombocytopenia, which results in a lack of platelets (thrombocytes), can thin the blood excessively and trigger the coagulation disorder. Blood clotting can be disrupted by blood cancer (leukemia) by cell degeneration.

Sometimes reduced blood clotting can also be specifically desired. This is the case, for example, in operations for the therapy of heart or cancer diseases. Diseases such as arteriosclerosis or thrombosis, which provoke increased blood pressure, often require relief of the vessel walls by medicinal blood thinners. These anticoagulant drugs include:

  • ASA (acetylsalicylic acid),
  • Clexane,
  • Heparin,
  • Marcumar,
  • Talithrom,
  • Monoembolex.

Important: The drugs mentioned should never be used without a doctor's prescription for the purpose of thinning blood. Treating physicians must regularly and closely monitor the blood coagulation values ​​in order to be able to recognize a fine line between the desired blood thinning and the uncontrolled tendency to bleed in good time.

Brain hemorrhage due to traumatic brain injury

External injuries in the area of ​​the head, for example due to accidents or the effects of violence, can lead to visible and hidden injuries. Visible injuries are usually medically treated and monitored quickly, so that any complications can be identified at an early stage. The much more devastating risk comes from the hidden injuries. Often, those affected are still conscious after a fall on the head, are responsive and, apart from a slight humming of the head, do not report any symptoms of concern.

Any violent impact on the head can theoretically lead to internal bleeding in the brain or between the meninges. If there is no external injury, it often remains undetected for hours or days and can thus worsen significantly if left untreated. Only when the blood begins to displace the soft brain substance due to the bony structure of the skull, do affected persons experience specific symptoms such as impaired consciousness or perception disorders and the true extent of the injury becomes clear.

Note: Especially blunt violent effects on the head and neck area should always be under special observation and should not be taken lightly, even if those affected appear to be in good health. Observations regarding the intracranial pressure mark can be of life-saving importance here.


A feared complication of cerebral hemorrhage that almost always occurs without counter-treatment is cerebral edema. It denotes swelling of the brain tissue caused by bleeding and increases the pressure exerted on the brain immensely. The most important symptoms of cerebral hemorrhage are therefore the so-called intracranial pressure signs, which indicate an increased pressure inside the skull. Especially in the case of accidents and the effects of violence as a cause, these signs can appear very late and only gradually indicate internal bleeding in the area of ​​the skull. Often, they are mistakenly mistaken for gastrointestinal complaints at the beginning of their appearance. Above all, nausea and vomiting in combination with fatigue or drowsiness make one think of food poisoning. For this reason, here is a detailed overview of all the intracranial pressure marks:

  • nausea
  • Vomit
  • a headache
  • fatigue
  • Attention and concentration disorders
  • Inner unrest
  • Spasticity of the upper and lower extremities
  • Changed speech behavior (lall, word finding disorders)
  • Difficulty breathing
  • Drowsiness
  • Changed pupil reaction
  • Sensation disorders or numbness

Danger: If the intracranial pressure symptoms remain undetected and the cause of the increasing intracranial pressure remains untreated, a seemingly harmless fall or shock can even be fatal if it has caused a cerebral hemorrhage! An extremely alarming intracranial pressure sign are sensation disorders.


A detailed patient survey at the beginning of the examinations is - if the patient is still conscious - extremely important for the doctor in the case of cerebral hemorrhage in order to be able to initiate targeted therapeutic steps as quickly as possible. Existing complaints, such as abnormal sensations at certain head areas, provide information on the location of the bleeding, for example. After the anamnesis, a careful examination using imaging techniques is also necessary to determine the exact extent of the cerebral hemorrhage and individual causes. In addition to X-ray examinations, CT and MRI are mainly used here. In addition, laboratory tests are possible, for example to discover or rule out blood, vascular or tumor diseases.


Bleeding from the brain, no matter what the cause, always requires medical treatment because if left untreated it can cause serious and irreparable damage to the brain and can even lead to brain death. The time that elapses between the appearance of the bleeding and the initiation of the first medical measures also plays a major role here and is decisive for success. The sooner treatment is given, the greater the likelihood that those affected will survive and the brain damage will be reversible.

Stationary monitoring

Above all, existing brain edema must be checked closely by medical staff, which is why monitoring in the intensive care unit is necessary. In addition, regardless of their state of consciousness, patients with cerebral hemorrhage may only be positioned in a semi-upright 30 ° upper body elevation, which must also be monitored in hospital.

Medical therapy

At the same time, decongestant drugs such as high-dose cortisone and excretion drugs such as diuretics can be used to reduce the fluid pressure on the brain. Breathing is often impaired as the brain swells, and oxygen therapy or even artificial ventilation is necessary.

Since high blood pressure is not infrequently the cause of cerebral hemorrhage, its treatment is also a focus of therapy. On the one hand, in the acute situation of cerebral hemorrhage, blood pressure should be kept in the normal range, whereby antihypertensive agents, both in tablet form and in the form of intravenous doses, can help reliably. On the other hand, the blood pressure should also be checked in long-term therapy and kept medication within the normal range. Antihypertensive medication could therefore become a lifelong treatment measure. Since bleeding in the brain is often associated with seizures before and afterwards, medication with anticonvulsants is advisable.

Surgical therapy

Depending on the location of the bleeding and the extent of the damage to be expected, surgical treatment is often unavoidable. The aim is to completely remove the bruise and eliminate the cause of the bleeding, for which a surgeon has to open the bony part of the skull (craniotomy). A particularly careful approach has top priority in this operation right from the start, since the brain is particularly sensitive to manipulations with external instruments and additional irritation of the brain tissue must be avoided.

Bleeding and malformed vessels can be closed with clips or coils to prevent further bleeding. In the process of healing, the brain later develops evasive blood vessels (collateral vessels) that take care of the areas of the brain that are switched off. At the end of the operation, the surgeon decides, depending on the extent of the swelling in the brain, whether the bony cranium can be replaced immediately or whether the complete closure of the skull must be postponed to a later point in time in order to completely swell it.

Long-term therapy

After the acute treatment of cerebral hemorrhage, long-term therapy always follows, the aim of which is to remedy any brain damage that may have occurred and to help those affected to have an adequate quality of life. Physiotherapeutic, speech therapy and occupational therapy measures can even lead to complete compensation for brain damage if used early. In addition, those affected by risk factors such as high blood pressure and arteriosclerosis receive appropriate training to change their way of life. (Ma)

Author and source information

This text corresponds to the requirements of the medical literature, medical guidelines and current studies and has been checked by medical doctors.

Miriam Adam, Barbara Schindewolf-Lensch


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ICD-Codes for this illness: I60-I62, S06ICD-Codes are internationally valid encodings for medical diagnoses. You can find e.g. in doctor's letters or on disability certificates.

Video: Intracranial Hemorrhage (October 2022).