Cerebral Hemorrhages

Epidural hematoma (bleeding)

Epidural hematomas are the “bleeding between the skull bones and the outermost and hardest membrane of the brain (dura)”. In other words, “hemorrhage on the outermost membrane of the brain”. Although these types of bleeding usually develop after traumas, they can rarely be occurred by other causes. Patients with this type of bleeding may develop fainting, loss of consciousness and coma so these patients with bleeding should be urgently operated. Although some patients experience partial improvement in the state of consciousness and partial regression of the complaints after the trauma, these patients should be operated immediately.

Symptoms

Headache, nausea and vomiting, mental fog and coma, different types of paralysis (loss of strength in the arm and leg, speech disorder, visual impairment, facial paralysis, etc.) shortly after the trauma.

Diagnosis

  1. Computed tomography (CT) is the first choice because it shows both bone tissue and bleeding.
  2. Magnetic resonance imaging (MRI) can be used in some cases to better see brain tissue and to search for different pathologies.

Treatment

Epidural hematoma is life-threatening, and an emergency case of neurosurgery. Sometimes these hemorrhages compress the brain by growing too fast and cause death. Therefore, it may be necessary to be operated immediately after the diagnosis. The first and only treatment option in these patients is surgery. Bleeding is discharged by operation and is stopped by coagulating the bleeding vein. Neurological findings are improved rapidly in patients that are taken into operation in time. The healing process is usually very fast.

Follow-up of patients who have been operated for traumatic epidural hematoma can be stopped after a while. In patients with epidural hematoma due to causes different than trauma, the cause of bleeding is investigated and long-term follow-up may be required.

Subdural hematoma

A subdural hematoma is a hemorrhage between the brain’s outer membrane and the brain, in other words, under the dura. Subdural hematomas may be acute and chronic.

Acute subdural hematomas are hemorrhages which develop suddenly and have a very high ratio of death and disability. Although the most common causes of these bleedings are traumas, it may also occur frequently in patients who are old and use blood thinners. It requires immediate surgical treatment.

Chronic subdural hematomas usually occur in older patients. These patients usually have mild head trauma 4-5 weeks ago. For example; the patient has hit his/her head to the cupboard door in the kitchen or, as a result of a slight slipping in the bathroom, he/she has hit his/her head. Most of these patients are patients using blood thinners. After minor traumas, it occurs due to rupture of small suspensory veins between the brain and the membrane and may take days or weeks to develop. In young and pediatric patients, it often occurs due to a drop of intracranial pressure.

Symptoms

In acute subdural hematomas, the symptoms may vary from headache to coma. Neurosurgeons often meet with these patients in the emergency department. The neurological status and general conditions of these patients who come to the hospital are generally bad (mental fog, coma, etc.).

Patients with chronic subdural hematomas usually have better status. Patients may consult with symptoms such as headache, speech disorder, weakness in the arm and/or leg, and other paralysis conditions, such as mental fog-coma.

Diagnosis

  1. Computed tomography is the first choice because it shows both bone tissue and bleeding well.
  2. In some cases, magnetic resonance imaging may be used to better be able to see brain tissue and to search for different pathologies.

Treatment

Acute subdural hematomas have a mortality rate of 90% despite all treatment and effort. One of the most important points in here is the immediate operation of the patients. Sometimes the patient may not be operated on because the patient’s general condition is very bad. Acute subdural hematoma may also develop due to blood thinners that elderly patients use and old age. Treatment of chronic subdural hematomas is also surgical. The time of surgery is evaluated according to the condition of the patient and the pressure of the hematoma to the brain.

Follow-up of the patients who have been operated for post-traumatic subdural hematoma can be stopped after a while. Long-term follow-up may be required in patients who have had epidural hematoma for different reasons. Long-term follow-up is required for chronic subdural hematoma especially in elderly patients who have a high rate of relapse.

Parenchymal hematoma

These types of bleedings are bleedings into the brain tissue. Sometimes there may be bleeding into the chamber which has cerebrospinal fluid that we call as brain ventricles. Although this type of hemorrhage is after head trauma or secondary to hypertension, sometimes it may bleed into the tumor. Posttraumatic hemorrhages are multiple and generally not very large in size. Bleedings secondary to hypertension are the bleedings to the major nucleus of the brain called basal ganglia. These bleedings can be large in size. Intra-ventricular hemorrhage can occur as a result of the opening of bleedings to there that connected with the blood pressure or as trauma or as a result of bleeding of vascular pathologies such as AVM or aneurysm.

Symptoms

Headache is one of the most common symptoms. Nausea and vomiting, different types of paralysis (speech, loss of strength, etc.), mental fog, drowsiness, not able to wake up and coma may occur.

Diagnosis

  1. Computed tomography is the best and fastest examination that shows trauma and bleeding. It should be done first in patients who are considered to have bleeding.
  2. Magnetic resonance imaging is used to evaluate the cause of bleeding and the state of brain tissue.
  3. Angio is used to detect such pathologies in bleeding that may be related to vascular pathologies. Can be performed as Digital Subtraction Angio (DSA), MR-Angio and CT-Angio

Treatment

If the size of bleeding is too large and life-threatening in parenchymal hemorrhage, let blood is done with operation. External ventricular drainage (EVD) can be placed to ensure drainage of blood in ventricular hemorrhages. A catheter is placed with EVD into the chamber which contains cerebrospinal fluid to allow the cerebrospinal fluid to flow out of the body. In such patients, the blood pressure to prevent re-bleeding should be normalized and the disease of patients with systemic diseases such as diabetes should be checked.

Subarachnoid hemorrhage

Subarachnoidal hemorrhage (SAH) is the type of hemorrhage between the brain tissue and the membrane, which is called arachnoid. Although the most common causes of such bleedings are traumas and aneurysms (vascular bubbles), they may also develop due to other vascular diseases such as tumor and arteriovenous malformation. One of the most common complications of subarachnoidal hemorrhage is hydrocephalus, especially if this hemorrhage is related to aneurysm (vascular bubbles). Hydrocephalus is the enlargement of the chambers with cerebrospinal fluid. Blood and blood products entering the subarachnoid space clog the small canaliculus that provides absorption of cerebrospinal fluid and can cause hydrocephalus.

Symptoms

Severe headache is one of the most common complaints. Nausea and vomiting, speech disorder, weakness and paralysis of other varieties, urinary and fecal incontinence, mental fog and varying degrees of coma can be seen.

Diagnosis

  1. Computed tomography is the best and fastest examination that shows trauma and bleeding. It should be done first in patients who are considered to have bleeding.
  2. Magnetic resonance imaging is used to evaluate the cause of bleeding and the state of brain tissue.
  3. Angio is used to detect such pathologies with bleeding that may be related to vascular pathologies. It can be done as Digital Subtraction Angio (DSA), MR-Angio and CT-Angio.

Treatment

In subarachnoidal hemorrhages, treatment is performed aimed at the cause of bleeding and hydrocephalus that may be developed. Aneurysm treatment should be performed in aneurysm-related bleedings. In the surgical treatment, the aneurysm is seen by opening the skull, it is peeled off from the surrounding tissues and the aneurysm neck is closed with clips and the filling of blood to the aneurysm and the bleeding is prevented. In the endovascular treatment, the aneurysm in the brain is filled with special metals by entering with the DSA as if it is done from the inguen artery, thus preventing the blood from filling and bleeding. The type of treatment is chosen after evaluation based on the location, size, of the aneurysm, general health status of the patient, and patient’s choice, and other conditions.

Subarachnoid hemorrhage may cause brain damage due to vasospasm, which means contraction of the brain veins. Surgeries to stop bleeding does not prevent vasospasm alone. Therefore, this type of patients may have a high mortality rate despite long intensive care and much effort.