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Cerebral Hemorrhages

Epidural Hematom (Kanama)

Epidural hematomas are defined as the “bleeding between the skull bones and the outermost and hardest membrane of the brain (dura)”. In other words, they are “hemorrhages on the outermost membrane of the brain”. Although this type of bleeding usually develops after traumas, it can rarely occur due to other causes. Since patients with this type of bleeding may develop fainting, loss of consciousness and comatose state, they should promptly undergo surgery. Although some patients experience partial improvement in terms of consciousness and partial regression of the complaints after the trauma, surgery must be performed on these patients immediately.

Symptoms

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

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

Epidural hematoma is life-threatening, and is classified as an emergency case in Neurosurgery. Sometimes these hemorrhages compress the brain by growing too fast and cause fatalities. Therefore, removal by surgery may be necessary immediately after the diagnosis. The first and only treatment option for these patients is surgery. The bleeding is discharged during the operation and is stopped by coagulating the hemorrhaging vein. Neurological findings rapidly improve in patients that are taken into surgery in time. The recovery process is usually very quick.

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

Subdural Hematoma

A subdural hematoma is the hemorrhage between the brain’s outer membrane and the brain, in other words, a hemorrhage that occurs 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 fatality and disability. Although the most common causes of these bleedings are traumas, they may also occur frequently in patients who are elderly and who use blood thinners. They require immediate surgical intervention.

Chronic subdural hematomas usually occur in older patients. These patients usually have a history of mild head trauma that occurred 4-5 weeks ago. For example; the patient may hit their head on the cupboard door in the kitchen or, hit their head as a result of a minor slip. Most of these patients are patients who are using blood thinners. After minor traumas, this condition occurs due to the rupturing 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 in the intracranial pressure.

Symptoms

In acute subdural hematomas, the symptoms may vary from headaches to coma. Neurosurgeons often encounter these patients in the emergency room. The neurological and general conditions of these patients who arrive at the hospital are generally bad (mental fog, coma etc.).

Patients with chronic subdural hematomas are usually in a better condition. Patients may be admitted with symptoms such as headaches, speech disorder, weakness in the arms and/or legs, other states of paralysis, and mental fog-coma.

Diagnosis
  1. Computed tomography is the first choice since it shows both the bone tissue and the bleeding in detail.
  2. In some cases, magnetic resonance imaging may be used in order to see the brain tissue better and to search for different pathologies.
Treatment

Acute subdural hematomas have a mortality rate of 90% despite all treatments and efforts. The important thing to note here is that these patients require immediate surgery. In some cases it may not be possible to operate on the patient due to their condition being very bad. Acute subdural hematoma may also develop in elderly patients and in patients who use blood thinners. Treatment of chronic subdural hematomas is also surgical. The time of surgery is evaluated according to the condition of the patient and the pressure exerted by the hematoma on the brain.

Monitoring of patients who have been operated for post-traumatic subdural hematoma can be ceased 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 since they have a high rate of recurrence.

Parenchymal Hematoma

This type of bleeding occurs as bleeding into the brain tissue. Sometimes there may be bleeding into the chambers filled with cerebrospinal fluid, which we call brain ventricles. Although this type of hemorrhage occurs after a head trauma or is secondary to hypertension, sometimes it may occur as bleeding into the tumor. Posttraumatic hemorrhages emerge from multiple points, and typically are not very large in size. Bleedings secondary to hypertension are bleedings into the major nucleus of the brain called basal ganglia. These hemorrhages can be large in size. Intra-ventricular hemorrhage may occur as a result of the hemorrhages associated with blood pressure, trauma or the bleeding of vascular pathologies such as AVMs or aneurysms.

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 being able to wake up and comatose state may occur.

Diagnosis
  1. Computed tomography is the best and quickest examination that shows both the trauma and the bleeding. It should be performed first in patients with suspected hemorrhage.
  2. Magnetic resonance imaging is used to evaluate the cause of the bleeding and the state of the brain tissue.
  3. Angiography is used to detect such pathologies in bleeding that may be related to vascular pathologies. These may be in the form of Digital Subtraction Angio (DSA), MR-Angio and CT-Angio.
Treatment

If the size of the bleeding is too large and life-threatening in case of parenchymal hemorrhage, the blood is discharged via surgery. External ventricular drainage (EVD) can be applied to ensure the drainage of blood in intra-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, in order to prevent recurrent bleeding, the blood pressure should be normalized and the condition of the 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 arachnoid membrane. Although the most common causes of such hemorrhages are traumas and aneurysms (vein bubbles), they may also develop due to other vascular diseases such as tumors and arteriovenous malformations. One of the most common complications of subarachnoidal hemorrhage is hydrocephalus, especially if this hemorrhage is associated to aneurysms (vein bubbles). Hydrocephalus is defined as the expansion of the chambers filled with cerebrospinal fluid. Blood and blood products entering the subarachnoid space obstruct the small canaliculi that ensure the absorption of cerebrospinal fluid and may cause hydrocephalus.

Symptoms

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

Diagnosis
  1. Computed tomography is the best and quickest examination that shows both the trauma and the bleeding. It should be performed first in patients with suspected hemorrhage.
  2. Magnetic resonance imaging is used to evaluate the cause of the bleeding and the state of the brain tissue.
  3. Angiography is used to detect such pathologies in bleeding that may be related to vascular pathologies. These may be in the form of Digital Subtraction Angio (DSA), MR-Angio and CT-Angio.
Treatment

In subarachnoidal hemorrhages, treatment is performed based on the cause of bleeding and hydrocephalus that may develop. Aneurysm treatment should be performed in aneurysm-related hemorrhages. In surgical treatment, the aneurysm is seen by opening the skull, the tissue is removed from the surrounding area, clips are placed on the neck of the aneurysm to prevent the blood from filling into the aneurysm and the bleeding. In endovascular therapy, the aneurysm inside the brain is filled with special metals by entering from the inguinal artery as in DSA application, to prevent the blood from filling in and avoid the bleeding. The type of treatment is selected after an evaluation based on the location and size of the aneurysm, the general medical condition of the patient, the patient’s preference, and other circumstances

Subarachnoid hemorrhage may cause severe brain damage due to vasospasm, which is a term referring to the contraction of the brain veins. Surgeries to stop the bleeding are not able to prevent the vasospasm alone. Therefore, such patients may have a high mortality rate despite long-term intensive care and efforts.

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