Brain Surgery and Neurosurgical Oncology
Cerebral Hemorrhage
On this page, Dr Christian Brogna explains the causes and treatment options of cerebral hemorrhage.
Causes of cerebral hemorrhage
Cerebral hemorrhage can be caused by:
- a brain tumor;
- a vascular malformation, a cavernoma, an aneurysm;
- a head injury;
- amyloid angiopathy (spontaneous brain haemorrhage).
What does spontaneous brain hemorrhage mean?
Spontaneous bleeding is believed to be caused by the rupture of small arteries in the brain, that occur in the absence of a head injury, haemorrhagic tumors, haemorrhagic conversion of an ischemic stroke, hemorrhage related to sinus venous thrombosis and in the absence of vascular malformations.
The most frequent spontaneous cerebral hemorrhage occurs at the bifurcation of small perforating arteries of the brain.
Several studies have shown that the last segments of these arteries have a higher risk of developing micro-atheromas and lipoyalinosis which are related to their spontaneous rupture (amyloid angiopathy).
Who is affected by brain hemorrhage?
The incidence of amyloid angiopathy and spontaneous cerebral haemorrhage increases with age. Since the age of the population is generally increasing, we will probably see an increase in spontaneous brain haemorrhages attributable to amyloid angiopathy.
There is a higher rate of spontaneous bleeding in men, as well as in patients who overuse alcohol or sympathomimetic drugs.
Cerebral hemorrhages typically dissect the planes between the different white matter fibers of the brain. This has a direct consequence on the type of surgical treatment chosen since in the context of cerebral haemorrhage there may be areas of the brain that are still intact and functioning, which must be preserved.
Which areas of the brain are most affected?
There are areas of the brain where spontaneous cerebral hemorrhage occurs most frequently: putamen (35%), subcortical cortex and white matter (25%), thalamus (20%), cerebellum (5%), brain stem (5%).
Several studies have shown that the brain hematoma can continue to expand after the initial event. In some patients, the hematoma may continue to increase in size in the 24 hours following the initial event.
If the patient’s age is the first risk factor for spontaneous cerebral hemorrhage, the most important risk factor modifiable through correct behavior is hypertension. Patients with a systolic blood pressure of more than 160 mmHg or a diastolic blood pressure of more than 110 mmHg have a 5-fold higher rate of cerebral haemorrhage than non-hypertensive patients.
It has been shown that blood pressure levels “reactive” to the increase in intracranial pressure due to cerebral haemorrhage, contribute to increase the volume of the hematoma and cause a clinical worsening of the patient. Therefore it is essential to pharmacologically monitor the blood pressure of those patients with cerebral haemorrhage.
Patients taking anticoagulants have a high risk of developing a larger hematoma and consequently a worse clinical outcome.
When a cerebral hematoma occurs in a patient who is administered anticoagulants, it is necessary to immediately stop the use of anticoagulants and possibly drugs that allow to restore normal coagulation. It is also highlighted that patients who use antiplatelet agents -es. aspirin – have a higher incidence and mortality risk from intracranial haemorrhage. It is not surprising that the combination of aspirin with clopidogrel synergistically increases the increase in the volume of cerebral haemorrhage.
Morbidity and mortality from spontaneous cerebral haemorrhage continues to be high. Only 20% of patients are functionally independent three months after the bleeding. Mortality 30 days after bleeding is about 40%. The presence of an intraventricular hemorrhage, that is an extension of the hemorrhage to the cerebral ventricles significantly increases the morbidity and the possibility of a good result is reduced.
Surgery for brain hemorrhage
Surgery in brain haemorrhages has two objectives:
The first is the reduction of the mass effect and the reduction of the intracranial pressure associated with it. The second is to keep intact that part of the brain that surrounds the hemorrhage which could be in a state of “still reverable ischemic penumbra”, that is reversible.
Surgical removal of a hematoma is generally performed through a craniotomy or a mini-craniotomy that allows access to the hematoma, possibly also using minimally invasive techniques. Surgical microscope as well as endoscopic techniques can be used to remove the brain hemorrhage.