Brain Hemorrhage Surgery

Overview:

A brain hemorrhage is a life-threatening condition that requires emergency and immediate medical intervention. It is considered as a type of stroke where any area of the brain bleeds as a result of a rupture in a brain artery or a blood vessel

In the head causing compression and irritation of the surrounding tissues resulting in swelling known as cerebral edema. The pooled blood then collects, causing a lump called hematoma that adds more pressure on the brain tissues, thus disrupting normal blood flow and oxygen supply to brain cells leading to their death and causing nerve damage. At this moment, functions controlled by the damaged cells are affected.

Causes:

There are a lot of contributory factors and causes that lead to brain hemorrhage including:

  1. Hypertension: Elevated blood pressure is a chronic disease that weakens the blood vessels wall over time, making it burst. It is the most common risk factor of brain bleeding, and it also raises the chance of spontaneous intracerebral hemorrhage from 2 to 6 times, which is accompanied by low brain hemorrhage survival rates. That’s why it cannot be left uncontrolled or untreated, mainly because it can easily be prevented.
  2. Head trauma: injuries are one of the significant causes of the bursting of any blood vessel in the head like car or sports accidents, depressed skull fracture, any head penetration, violent activities, and falls.
  3. Some diseases like liver disease and bleeding disorders such as hemophilia & sickle cell anemia, as well as other conditions that also lead to thrombocytopenia (decreased platelets level), facilitating bleeding. 
  4. Amyloid Angiopathy: it’s an abnormality in the walls of arteries or the blood vessels in the head as protein is formed within them. It can be genetic or acquired as a result of some diseases like hypertension or acquired by Age. Amyloid angiopathy may result in simple tiny bleedings without any notice before a critical one.
  5. Blood thinners: Drugs like warfarin, heparin, or coumadin used to prevent the formation of blood clots may leave the body in a condition that is prone to hemorrhagic stroke events.
  6. Unknown etiology.
  7. Ruptured brain Aneurysm: a balloon-like bulge abnormality in an artery wall that ruptures.
  8. Arteriovenous malformations (AVM): an abnormal tangle of blood vessels that connect arteries and veins, it affects the normal flow of blood. It may be seen at birth but also may never be diagnosed unless the patient starts to develop symptoms.
  9. Pregnancy-related conditions: Such as eclampsia and postpartum vasculopathy.
  10.  Others: like smoking, Age, abnormally formed blood vessels in the brain, especially in diagnosed young people, some drugs including cocaine and methamphetamine. 
  11. Brain tumor: a bleeding brain tumor is a rare complication of some brain cancers; it mostly happens in patients over 60 years of Age or patients who undergo head or neck radiation treatment. Tumors can be primary that originates in the brain tissues itself or metastatic that originates in any other tissue or part of the body and spread to reach the brain. Although the probability of having a bleeding brain tumor is rare, gliomas, pituitary, and those associated with melanoma tend to have a high risk of bleeding in contrast with meningiomas or brain metastases from breast and lung tumors.

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Symptoms:

Symptoms vary according to the location of the bleeding, functions that are affected correspond to area damaged but the most common symptoms are:



  • Severe headache.
  • Nausea and vomiting.
  • Increase in intracranial pressure due to pressure applied by large mass hematoma.
  • Collapsing.
  • Some patients suffer from ear bleeding.
  • Coma even if not yet diagnosed and loss of consciousness.
  • Seizures.
  • Confusion and delirium.
  • Lethargy.
  • Apathy.
  • Face, leg,arm weakness or tingling and paralysis that usually appears at one side only.
  • Changes in sense of taste.
  • Changes in vision.
  • Dysphagia or difficulty swallowing.
  • Dizziness and loss of balance.
  • Trouble speaking and understanding.
  • Difficulty using fine motor skills appearing as hand tremors.
Brain Hemorrhage Surgery 1
blood vessels in head

Diagnosis:

The physician assesses all the patient’s symptoms along with asking about family history, current medical conditions or disease, and any medications the patient uses.

Then some imaging tests and diagnostic ones should be done to confirm the diagnosis and determine the appropriate intracerebral hemorrhage treatment plan, thus increasing the recovery chance of the patient as well as brain hemorrhage survival rate.

These tests include:

  • CT scan: to see if a bleeding exists.
  • MRI: to know the cause of the hemorrhage.
  • Lumbar puncture: It’s not always done in all cases as it may worsen symptoms and deteriorate the case but it helps some physicians sometimes, it’s done by inserting a needle between 2 lumbar vertebral discs for a cerebrospinal fluid examination.
  • Neurological examination: It may be performed to reveal the swollen optic nerve.
  • Measuring intracranial pressure: done to monitor bleeding by special instrument and may be performed also by repeated ct scans.
  • Angiogram: a catheter is inserted into the groin or arm artery till it reaches the brain then contrast dye is injected through the catheter to facilitate the tracking of blood flow in the x-ray and also excluding any abnormalities such as AVM or aneurysm.
  • Computed tomography angiography: injection of dye into bloodstream to see the arteries of the brain clearly in CT scan.
  • Some other tests include electrocardiogram, complete blood picture (CBC) to check if there’s any blood clotting disease, inflammation or any immune system disorder.
  • In case the patient is suspected to have a bleeding brain tumor after CT scanning, MRI with contrast should be done to confirm diagnosis.



Treatment:

Choosing Intracranial hemorrhage treatment varies according to the severity of the patient’s case, location, cause of the damage as well as the size of the hematoma, and the extent of swelling. But in all cases treatment should be started as soon as possible as the patient can get the best results if the bleeding is noticed early and intracerebral hemorrhage treatment is done in the first 3 hours to decrease the chance of brain damage and increase the chance of recovery and brain bleed survival rate.

In some cases, mild hemorrhage subsides on its own within two weeks, but any brain damage happened may not be reversible. Others may require brain hemorrhage surgery if the bleeding is severe or if the hematoma is larger than 3 cm3 or in the presence of lobar bleeding and structural vascular lesions in young patients.

Brain hemorrhage surgery is necessary for relieving pressure applied to the brain by removing pooled blood and stopping bleeding and swelling as it can also repair the damaged blood vessel in the head.

Some patients’ condition doesn’t tolerate brain hemorrhage surgery; it’s determined by the health care expert according to the patient’s age and cerebrovascular condition, including location, neurological deficits, and extent of damage that occurred. His general health status is also so important to determine which intracerebral hemorrhage treatment is suitable and be sure if the brain hemorrhage surgery is the best option for him or not.

Types of surgeries:

1) Decompression Surgery:

Decompression surgery is used to decrease pressure applied to the brain by removing or draining the pooled blood and to repair the damaged vessels in the brain once again. There are four standard methods used to drain the blood from a ruptured blood vessel in the head as :

  • Simple Aspiration:

In this procedure the physician makes a small hole in the patient’s skull and the drainage process is done using a needle. Pros: non-invasive. Cons: Hard to determine the exact location of bleeding. The physician may not be able to drain the pooled blood completely.

  • Craniotomy:

           This method is mainly used when the patient has a large sized hematoma or when the pressure is affecting crucial functions as in case of  brain stem hematoma. It’s also used mainly if the hematoma is near the skull surface or is accompanied by AVM or tumor.

It’s an open surgery by which the health care expert removes a portion of the skull or opens it’s cavity to drain the blood as well as repair blood vessels.  Craniectomy incision is also an intracranial hemorrhage treatment, done by partial removal of the skull only facilitating swelling expansion.

  • Endoscopic evacuation:

It resembles the Simple aspiration method because the physician makes hole in the patient’s skull but the main difference is that an endoscope is the instrument used to drain the hematoma.

  • Stereotactic aspiration:

This method is too precise and provides accuracy. The hematoma location is determined using a CT scan and drainage is done by using a developed suction instrument and a stereotactic head frame is used to insure the patient immobilization during the procedure. It’s mainly used with deep hematomas.



2) Clipping procedure:

Almost used if the bleeding is caused because of Aneurysm, and it’s done by the craniotomy method. Clipping surgery is a good procedure that helps increase brain hemorrhage survival rate as it gives the patient a chance of recovery & therefore confirms percentage numbers of brain hemorrhage surgery success rates.

3) Brain path surgery:

If the patient is suffering from a bleeding brain tumor, this surgery is obtained to remove it using a port. It can also be used to remove a blood clot.

Pros: it has less complications & leaves less scar than other types of surgeries. It also has a fast recovery and is also considered a cause of high brain bleed survival rate.

In mild bleeding brain tumor cases or cases having low blood volume pooled, the intracerebral hemorrhage treatment may not include surgery. The patient only undergoes more investigative tests, and an oncologist determines the suitable treatment plan for his bleeding tumor, even chemotherapy or radiation.

Brain hemorrhage surgery success rate is measured by assessing the patient’s symptoms like a headache after the surgery besides performing further investigations and tests. Patients experiencing critical symptoms possess a low percentage of a brain bleed survival rate.

Intracranial hemorrhage treatment is not only limited to surgeries. Despite the high brain hemorrhage surgery success rates, certain medications must be used in parallel to help relieve patient’s symptoms as:

  • Painkillers for severe headache.
  •  Corticosteroids.
  • Diuretics for swelling.
  • Anticonvulsant drugs as phenytoin to prevent any attacks, some health care professionals also give them to the patient after the surgery to help control or prevent post traumatic epileptic attack.
  • Nimodipine to prevent any spasm that may be present in arteries.
  • Laxatives to facilitate passage of stool without straining.
  • Iv nutrition or stomach feeding tube to feed the patient especially those  with dysphagia.
  • Drugs to control blood pressure.
  • H2 receptor antagonists or proton pump inhibitors to prevent stress ulcers.
  • Vitamin k, protamine or platelet transfusion in patients receiving blood thinners or anticoagulants to restore normal clotting.

There are some other adjunctive ways that can be used in  intracerebral hemorrhage treatment as:

  • Draining of the cerebrospinal fluid by a catheter (VP shunt) to free some space to blood therefore prevents brain cells damage.
  • Monitoring of intracranial pressure and blood pressure using their specific instruments that measure them repeatedly.
  •  Insertion of a catheter.

Patients are monitored in the intensive care unit after the injury to ensure the stability of their case before leaving the hospital, and those with any lasting problems like coma or paralysis will require nursing home care to avoid deterioration or recurrence.

Intracranial hemorrhage treatment is not that easy, and it requires long term monitoring & rehabilitation programs to facilitate restoring the patient’s everyday life activities through physical, occupational & speech therapies. These therapies help them regain the functions of their brain, muscle movements, and some skills as well as independence and their ability to speak.



Recovery and prognosis:

In some conditions, after receiving an intracranial hemorrhage treatment prognosis is poor, brain bleed survival rate is not too high in general, and it depends on how well any patient can respond to the treatment protocol along with the severity of his case and his age. Also, surgery may not have the same relieving effect over them all, even if the brain hemorrhage surgery success rates are high.

Some patients do recover entirely as those who have good general health, they own the highest number of brain hemorrhage survival rates, but recovery is slow and may take weeks, months, or even years.

However, brain hemorrhage may leave some complications with no full recovery as loss of some brain functions, paralysis and may lead to death even if suitable treatment was given, especially those suffering from brain stem hemorrhage.

By numbers, around 30-60% of hemorrhagic stroke patients die, and People who suffer once from a hemorrhagic stroke can have a high risk of developing the second one by 25% in the future, but among this 25% many are improved. The blood absorbs the hematoma restoring functions and relieving symptoms.

The death rate of spontaneous brain bleeding is 34-50% in the first 30 days after injury, 50% of them may die within the first two days of bleeding. People who survive have a mortality risk of 27% higher than ordinary people. Those who are having aneurysm can also have a low brain bleed survival rate

And if survived, 50% of survivors may die in the first month of receiving treatment, and the rest may suffer from some neurological problems. AVM diagnosed patients are having a high brain bleed survival rate, and mortality percentage reaches 15% only. 

Half of those who don’t undergo surgical treatment may have a recurrent one within the next six months, and this proves the importance of surgical intervention and supports brain hemorrhage surgery success rates numbers.

BY: GHADEER IBRAHIM



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