Intracranial Hemorrhages

Intracranial hemorrhage means bleeding in the brain tissue (intracerebral) or bleeding between the surrounding membranes and bone (subarachnoid, subdural, epidural). All of these hemorrhages may occur either after trauma that means after head impact exposure due to any cause or as a result of hypertension and any other systemic disease.

Intracerebral Hemorrhages

It occurs when the walls of blood vessels, especially small vessels in specific regions, which feed the brain, rupture and bleed into the brain and damage the brain tissue. Approximately 12-15 cases are seen in 100,000 people each year and this rate increases over the age of 40 years.  The rate of male to female is 1\1,67. The risk factors are hypertension, amyloid angiopathy, trauma, alcohol and nicotine.  In addition, aspirin, non-steroidal anti-inflammatory agents and thrombolytic agents used for therapeutic purposes may also cause that.  Cerebral blood vessels wear out with advancing age and lose their elasticity.  As a result of diseases such as hypertension and amyloid angiopathy, the walls of these vessels, which have lost their elasticity, rupture and the blood leaks into the brain tissue.  This blood causes a mass effect and destroys the brain tissue, accumulating in the brain tissue Meanwhile, this mass effect causes ischaemia by damaging the circulatory system of the brain.

Clinically, it shows up with unilateral loss of strength, headache and changes in consciousness.  Besides that, speech disorder, seizure, nausea and vomiting may also occur.

A detailed anamnesis should be gained for pre-diagnosis.  Computed tomography and magnetic resonance imaging techniques are used for the diagnosis.  Computed tomography is preferred because of its short duration and better diagnostic accuracy.

The initial step in treatment is to maintain the respiratory and circulatory system to protect the vital functions of a patient.  By evaluating the volume, localization of the hemorrhage and the neurological condition of the patient, it is decided whether the treatment will be surgical or medical.  The surgical treatment is the removal of the hemorrhage that has accumulated and causes mass effect in the brain tissue.  The medical treatment are the use of drugs that will lower the intracranial pressure and reduce the edema around the hemorrhage.  Antiepileptic drugs that prevent the patient from having a seizure are also started for preventive purposes.

Subarachnoid Hemorrhage

They are hemorrhages that occur below the arachnoid membrane surrounding the brain.  The incidence is 10-16\100000. Risk factors are genetic factors, smoking, alcohol, hypertension and drug habits such as oral contraceptives, cocaine, amphetamine.  The most common causes are aneurysm, as well as hypertension, atherosclerosis, arteriovenous malformations, brain tumours, bleeding disorders, encephalitis, meningitis, meningoencephalitis, anticoagulant treatment complications, head trauma and unknown causes.

The most common symptoms are severe headache and neck stiffness.  In addition, there may be signs of nausea, vomiting, dizziness, diplopia (double vision), seizures, clouding of consciousness and other intracerebral hemorrhage findings that may accompany.  At first, the diagnosis is to detect hemorrhage with computed tomography that provides fast results.  The next thing to do after the hemorrhage is identified is angiography to visualize the blood vessels of the brain.

If an aneurysm is detected as a result of angiography, the aneurysm should be removed circulation by surgical or endovascular techniques according to its localization and configuration.

Despite all advancements, 25-30% of these patients are deceased before arriving at a hospital and 30-50% of the remaining patients cannot saved.

Epidural Hematoma

They are hemorrhages that occur between the tough outer membrane of the brain (dura mater) and the skull.  They occur as a result of damaged vessels on the dura after trauma, usually accompanied by a fracture in the skull bone.  They are seen in 0.2-0.6% of all head traumas.  The clinical signs comes up in three forms: the first one is lucid interval (loss and regain of consciousness), the second one is the total loss of consciousness and never regained, the third one is in form of clouding of consciousness.  It can be diagnosed by computed tomography and also magnetic resonance imaging can be used, but computed tomography is preferred since it provides results much earlier and the time plays a vital role.

The treatment is follow-up and surgery according to the amount of accumulated blood between the dura and the skull and the degree of the compression on the brain.  If the amount of the accumulated blood is very little, the patient can be monitored closely, keeping under observation. If the decision is surgery, it should be carried out very quickly.  The blood between the dura and the skull is removed surgically and the bleeding focus is found and stopped.  The results are gratifying after the surgical treatment.  Success rates after the treatment are between 55-89% and mortality rates are between 5-29%.

Subdural Hematoma

Subdural hematoma is seen in 8-57% of patients who have head trauma.  It is a blood accumulation due to the damage of vessels between the dura and the brain tissue.  In 50% of the subdural hematoma cases, there are also other additional pathologies in the brain.  Usually, patients are admitted with very serious neurological disorders and 50% of the patients are unconscious.  The best diagnosis technique is computed tomography, and magnetic resonance imaging may also be used to diagnose it.

The treatment of hematomas with mass effect and neurological disorders is surgery.  The accumulated blood between the brain and the dura is removed surgically and the bleeding focus is found and taken under control.  Mortality rates range between 42-90%, this rate much higher than epidural hematomas.