ENDOVASCULAR NEUROSURGERY

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ENDOVASCULAR NEUROSURGERY

Cerebral Hemorrhage

A Cerebral Hemorrhage is a bleeding inside the skull. It can be spontaneous or traumatic, following head injury.

There are different types of hemorrhages according to the exact intracranial space in which they occur. They are classified as follows:

1. Epidural hematoma (EDH). The hemorrhage lies between the skull and the dura mater, the outermost membrane covering the brain. It is mainly traumatic in origin, resulting from hemorrhage from a skull fracture and/or a tear in the middle meningeal artery which supplies with blood most of the dura mater. Spontaneous epidural hematomas are extremely rare. Epidural hematomas produce symptoms by causing a mass effect which results on pressure of various parts of the brain. A large epidural hematoma can be life threatening and requires emergency surgical intervention for its evacuation. Nevertheless it carries a mortality of 5-10%.

2. Acute subdural hematoma (ASDH). It lies between the dura mater and the arachnoid, the second membrane covering the brain. It is usually traumatic in origin but it can rarely be spontaneous, following rupture of a brain aneurysm or AVM or blood coagulation disorders due to disease or medical treatment. A subdural hematoma is considered Acute if it is discovered up to 3 days following the injury. ASDHs also produce symptoms due to a mass effect. An acute subdural hematoma usually requires surgical evacuation and can also be life threatening. Direct ijury to the underlying brain tissue, which usually accompanies an ASDH can produce mild or severe neurological deficits, which can resolve or be permanent. It carries a mortality rate of 50-90% depending on the severity of the conditon of the patient upon arriving at the hospital. This condition is affected mainly by the underlying brain damage and not the ASDH itself.

3. Subacute subdural hematoma (SASDH). It lies in the same space as the ASDH but is mainly traumatic in origin, due to a mild head injury which may have occured days ago. A subdural hematoma is considered Subacute if it is discovered from the 4th day up to the end of the 2nd week following the injury. It enlarges slowly until it reaches a size which can produce neurological symptoms through a mass effect. It requires surgical treatment and the recovery is spectacular.

4. Chronic subdural hematoma (CSDH). Exactly the same location and origin as the SASDH but it is discovered later than 2 weeks following the injury. The reason for this discrimination is the different consistency of the blood in these two hematomas. Same course and treatment as the SASDH.

5. Subarachnoid hemorrhage (SAH). It occurs in the subarachnoid space which lies between the arachnoid and the pia mater, the innermost membrane covering the brain. The main causes are ruptures of brain aneurysms or AVMs, but it can also occur following head injury. Therefore it is usually spontaneous and characterized by sudden onset of severe headache, rigidity of the neck muscles, nausea, vomiting and possible neurological symptoms like alteration of the level of consciousness, and loss of motion or sensation in various parts of the body. The course of subarachnoid hemorrhage is usually characterized by a deterioration in the clinical condition which occurs around the 4th to 7th day following the episode. This deterioration is caused by vasospasm which is constriction of the arteries inside the skull and diminished delivery of blood to the brain. Subarachnoid hemorrhage does not produce a mass effect on the brain and no emergency surgery is required to evacuate it.
SAH can be a devastating disease. It is estimated that 10-15 of patients with SAH never reach the hospital alive. Of those who do, 10% die in the first few days. The overall mortality is 50-60% in the first 30 days following hemorrhage and of those who survive, 50% are left with a permanent major neurological deficit.

6. Intracerebral hemorrhage (ICH). It is a hemorrhage inside the brain tissue and it is mainly caused by trauma, hypertension, rupture of an aneurysm or an AVM, artery disease, coagulation disorders or brain tumor. It can produce very mild symptoms like headache or it can be life threatening, according to its location and size. Emergency surgery is required in severe cases with a large hematoma mass. The overall mortality rate is 44%.

7. Intraventricular hemorrhage (IVH). This is a hemorrhage inside the ventricles of the brain, cavities in which circulates the Cerebrospinal fluid (CSF). It can be caused mainly by rupture of an aneurysm or an AVM or head injury. It can become very quickly complicated by Hydrocephalus, a conditon due to blocking of the circulation pathways of the CSF by blood clots,leading to enlargement of the ventricles and compression of the brain against the rigid skull. Post hemorrhagic acute hydrocephalus requires a surgical diversion of the CSF, called ventriculostomy, usually solving the problem.

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