Cerebral hemorrhage: causes and therapy | Coma and death

The cerebral hemorrhage is a type of stroke.

It is caused by damage to an artery in the brain, which leads to the formation of a hematoma in the surrounding tissues.

What happens during a cerebral hemorrhage?

If the blood from a hemorrhage irritates the brain tissue, this leads to fluid accumulation (cerebral edema).

Blood and fluid:

1. Increase pressure on the surrounding brain tissue,
2. Reduce blood circulation,
3. Kill brain cells.

The bleeding may originate from:

• The inside of the brain,
• The skins that surround it (dura mater, arachnoid and pia mater),
• The space between the bones of the skull and the meninges.

Causes of cerebral hemorrhage

High blood pressure: If high blood pressure is not adequately controlled for a long time, the vessel walls are weakened and the risk of intracranial hemorrhage increases.

Since smoking is a risk factor for elevated blood pressure, it is advised to quit smoking.

Pathogenesis

Hypertensive bleeding is caused by microaneurysms of deep arteries (which penetrate deep brain structures).

Rupture of the aneurysms leads to the formation of bleeding and, therefore, intraparenchymatous hematomas.

Hematomas release substances that attract fluids for osmosis.

The result is the formation of edema (accumulation of fluids) in the vicinity of the hematoma.

This edema can be seen on the first day, it reaches its greatest extent between the 3rd and 5th day.

The edema can cause other complications, for example, herniations.

Aneurysm: The blood vessel swells and the vessel walls weaken. The tender walls of the aneurysm can burst and lead to bleeding:

1. In the subarachnoid space,
2. In the brain.

Arteriovenous malformation (AVM)

These are groups of large hypertrophied arteries that end in the veins without an intermediary of capillaries.

They are blood vessels that form very dense central tangles.

From here, large vein collectors (canals) emanate, which are collection rooms for the blood that leaves the central area.

In AVM, the vascular tissue is very weak and bleeding can easily occur.

AVM is usually congenital (it has existed since birth).

When those affected are 20-40 years old, they can tear.

The surgeon can perform surgical removal of the AVM because when the central nervous system developed, it found alternative ways to obtain blood despite this malformation.

Arterio-venous fistulas

These are malformations due to inflammation:

• The large cerebral veins,
• The venous sinus (venous channels in the hard meninges).

They are channels that connect veins and arteries directly with each other.

The result is venous hypertension, which sometimes affects the soft meninges and increases the risk of cerebral hemorrhage.

Cavernoma or venous angioma

It is a group of adjacent blood vessels (which can be thrombosed) with greatly reduced blood flow, you hardly see them at all, not even in a vascular image.

If these cavernomas bleed for the first, second or third time, they are a risk.

Radiosurgery and endovascular therapies are not effective because they cannot be made visible with angiography.

Moyamoya disease is a congenital disease, characterized by the appearance of stenosis and occlusions in the area of the internal carotid artery and its branches.

The result is an abnormal arterial circulation at the base of the brain.

Rarely, the circulation in the posterior area is included.

Moyamoya disease can cause:

• TIA or minor strokes in children,
• Intraparenchymatous or subarachnoid cerebral hemorrhage in adults.

Amyloid angiopathy

The accumulation of amyloid substances in the inner layer of the vascular walls leads to fragility of blood vessels.

The result is a whole series of recurring lobar bleeding.

In general, small asymptomatic bleeding takes place.

In certain cases, however, they can become much larger and have corresponding consequences.

Trauma: In children and generally in people under 50 years of age, head trauma is the main cause of cerebral hemorrhage. In the elderly, subdural hematoma occurs most often as a result of minor head injury.

Pregnant women who suffer from eclampsia have a greater risk of cerebral hemorrhage before and after childbirth.

Genetic predispositions: Neonatal cerebral haemorrhage occurs mainly in premature births, as the organs are not yet fully developed and the capillaries are still very fragile.

Medications and drugs that can cause cerebral hemorrhage:

• Cocaine
• Amphetamines
• Warfarin
• Heparin

Diagnosis of cerebral hemorrhage

Diagnosis is made by means of some devices through physical and neurological examination of the patient.

The doctor can perform:

• Computed tomography (CT), very good for distinguishing between hemorrhagic or ischemic stroke, you actually see a hemorrhage better in CT than in MR,
• magnetic resonance imaging (MRI), makes visible an edema that forms around a lesion,
• Angio-RM: Allows the visualization of possible arterial malformations, is used for bleeding with atypical localization,
• Cerebral angiography with contrast agent: Used to detect possible malformations that can be corrected by endovascular means.

Sometimes people with this problem have normal results on CT or MRI.

In this case, a lumbar puncture (removal of cerebrospinal fluid from the lumbar region by means of a cannula) is required to establish the diagnosis.

The affected person has blood in the cerebrospinal fluid.

In rare cases, cerebrospinal fluid testing may be negative in the first few hours after bleeding begins.

Sometimes angiography in patients with a cerebral hematoma has other intact aneurysms (unrelated to bleeding).

The doctor may perform tests to detect whether there are:

• Kernig sign: The patient cannot fully stretch one leg if it is bent at right angles (90°) in the hip.
• Brudzinski sign: patient lies on his back, when the doctor bends his head forward, the patient bends the knees and hips.

Treatment of cerebral hemorrhage

In the acute phase and when the patient arrives at the emergency room, therapy consists of:

• preservation of vital parameters,
• protection of the respiratory tract,
• lowering intracranial pressure with mannitol or cortisone,
• Balancing the electrolytes (mineral salts) into the normal range.

Immediately afterwards, diagnostic examinations are carried out to identify the cause of the disease.

A mild cerebral hemorrhage heals spontaneously, because the hematoma in the skull is broken down again.

If the bleeding is caused by high blood pressure, the doctor can prescribe pressure-lowering drugs that lower blood pressure and maintain it adequately (the upper pressure must be around 130 mmHg).

A pressure-lowering medication must not be exaggerated in the acute phase, because this can cause:

1. A reduced blood flow in some parts of the body,
2. Bradycardia (slow heartbeat).

Treatment of endocrine hypertension by:

• Osmotic diuretics – mannitol 20%, must be administered gradually throughout the day, otherwise there may be a recurrence of edema and thus increased intracranial pressure.
• Ventricular drainage: When the hemorrhage spreads to the ventricles of the brain, it blocks the outflow of cerebro-spinal fluid.
• The result is acute hydrocephalus.
• In this case, ventricular drainage is required (for example, ventriculo-peritoneal drainage) to drain cerebrospinal fluid and reduce internal intracranial pressure.
• Clearing of the hematoma (cerebral hemorrhage) after creating two small openings in the skull.

Therapy of subarachnoid hemorrhage

In the case of SAB, the cause is usually an aneurysm. In this case, emergency surgery must be performed to prevent complications

In addition, control and prevention of vasospasm is fundamental. This appearance is characterized by penetration of blood into the subarachnoid space and leads to vasoconstriction. After the third day, the risk of vasospasm is increased by bleeding.

In these cases, surgery must be performed before vasospasm occurs, as this can cause:

• Reduced blood flow,
• The death of the affected brain tissue.

Moderate bleeding into the subarachnoid space is tolerated (causes only headaches), while vasospasm leads to ischemia in the outflow area.

Therapy of AVM

Treatment of AVM depends on:

1. age of the patient,
2. Type of angioma.

In an emergency situation, if the AVM ruptures and causes bleeding, treatment may be:

• Conservative

The choice depends on the amount of blood loss and localization.

In a non-acute phase, i.e. when the AVM is still intact, the therapy can be:

• Conservative, if the risk of treatment is higher than the persistence of angioma
• Surgically for a small angioma that allows complete healing,
• Endovascular (embolization) is not definitive, but absolutely necessary to reduce blood flow and the volume of the angioma when it has become quite large.
• Radiosurgery is a treatment with radiation energy for small and deep-seated angiomas (possibility of angioma closure to 80% in 2 years after treatment).
• Combined treatment of surgery, embolization and radiosurgery, however, with a small angioma, only surgical intervention is performed.

When do I have to operate on a cerebral hemorrhage?

The last treatment option is surgery. The patient is operable if the hemorrhage is larger than 3 cm.

Surgical treatment of spontaneous hematomas is highly controversial because the results are not always good.

According to Siddique MS et al. (Department of Surgery (Neurosurgery), University of Newcastle upon Tyne, UK), the indications for treatment are:

• Symptomatic hematoma, when the pressure of the blood volume causes symptoms
• The localization of the hematoma must be surgically achievable, only superficial hematomas are operated on
• Adolescent age so that the patient can recover well. Rarely patients over 70 years of age are operated on
• Clot volume between 20 and 80 ml
• Displacement of the midline / increase in intracranial pressure
• Cerebellar hematoma with an extension greater than 3 cm or with causing hydrocephalus.

Contraindications are:

• Serious coagulation problems
• Patient with only mild symptoms
• Low or unreachable fit
• Advanced age (> 75 years)
• Mass bleeding

Surgical intervention for cerebral hemorrhage

Endovascular intervention for cerebral hemorrhage caused by an aneurysm

Endovascular surgical treatment (coiling) is the most common operation for an aneurysm.

• A catheter is inserted into the artery via the groin and advanced to the aneurysm in the brain.
• To guide the catheter, the X-ray image is checked.
• At the tip of the catheter is a platinum thread or spiral that is placed in the aneurysm and blocks blood flow.

After the operation, the stay in the hospital lasts one or two weeks until the patient is out of danger again.

In some cases, rehabilitation must be carried out afterwards.

If the hematoma has spread, the surgeon places drainage to avoid further complications.

This type of surgery only closes the artery completely in 70% of cases.

Neurosurgical intervention (clipping)

The procedure is performed under general anesthesia.

The surgeon:

• Opens the skull,
• Pushes the brain tissue to the side,
• Makes the aneurysm visible.
• Then the surgeon positions a surgical clip at the base of the blood vessel.
• The clip seals the aneurysm and thus prevents blood flow.

In the case of an uncomplicated operation, the hospital stay is four to six days.

Full recovery usually takes several weeks to months.

Prevention of cerebral hemorrhage

In newborns, there is no suitable method to prevent cerebral hemorrhage.

Pregnancy. Proper care of mother and child during pregnancy and after childbirth is important to prevent the risk of cerebral hemorrhage.

Aspirin or anticoagulants must be taken with caution.

Blood disorders such as hemophilia, sickle cell anemia, leukemia or thrombocytopenia increase the risk of bleeding.

Preventive measures may concern treatments of circulatory diseases.

Monitoring blood pressure is important to make sure that blood pressure does not rise too high.

Chances of survival and prognosis for cerebral hemorrhage

In general, the prognosis depends on the size of the hematoma, the extent of brain swelling and the patient’s state of health.

Many patients survive in difficult conditions, but some may fall into a coma.

Some heal completely, while others completely lose their previous abilities.

It is impossible to say how long the patient will be able to live, especially if the patient is in a coma. No one knows when he will wake up again.

Epidural hemorrhage

In this case, about 15-20% of patients die, even with appropriate treatment.

Subdural hemorrhage

The prognosis is based on the initial injury and the time that has passed since the first symptoms.

In the case of acute subdural hematoma, symptoms develop within 24 hours of the start of bleeding.

In this case, a mortality rate of 50-80% is observed.

Subarachnoid hemorrhage

According to the Mayfield Certified Health Information:

• One third of patients who have had a subarachnoid hemorrhage survive without consequences,
• One third develop a disability,
• A third do not survive.

Ventricular hemorrhage

The spread of bleeding to the ventricles is a particularly poor prognostic sign, with mortality between 50% and 80%.

Source: Holly E. Hinson at all (Holly E. Hinson, Neurosciences Critical Care Division, The Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287)

Brain haemorrhage

According to a study by William J. Powers, M.D. (Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC), mortality in the first 30 days is between 35% and 52% of those affected.

In the case of AVM:

• If mortality is 25%,
• 43% of patients develop motor or cognitive impairment,
• 33% have no consequences.

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