Management of Intracranial Hemorrhage

Introduction:

Intracranial hemorrhage is bleeding in the brain, its cavities, or the spaces surrounding the brain (between the brain and the skull). These life-threatening brain bleeds generally are sudden in onset and can lead to brain damage or death. The cause of the bleeding, the location, how promptly treatment was initiated, age, and the patient’s general health decide the patient's survival rate. Once the cells in the brain are damaged and die, they do not regenerate, leading to severe disability (mental and physical). Thus, prompt management of intracranial hemorrhage is essential to prevent disabilities and death.

What Are the Types of Intracranial Hemorrhage?

Intracranial hemorrhage can occur in the head in the following ways:

1. Bleeding occurs between the skull and the brain's outermost membrane (epidural bleed).

2. Bleeding occurs between the membranes lining the brain (subdural and subarachnoid hemorrhage).

3. Bleeding within the brain tissue (intracerebral hemorrhage).

4. Bleeding in the cavities in and around the brain (intraventricular hemorrhage).

What Are the Common Causes of Intracranial Hemorrhage?

The following can cause bleeding in the brain and skull:

1. Head injury due to serious falls and accidents, such as road traffic accidents.

2. High blood pressure (causes the blood vessels in the brain to burst or leak).

3. Blot clots or fat deposits in the blood vessels to and from the brain (damages the blood vessel).

4. Rupture of weak spots (cerebral aneurysm) in the brain's blood vessels.

5. A leak from an arteriovenous malformation (abnormally connected blood vessels).

6. Bleeding disorders.

7. Medications such as blood thinners.

8. Tumors or growth in the brain.

9. Heavy smoking, alcohol, and drug use.

10. Abnormal collagen in the brain's blood vessel walls (making them weak and rupturing).

What Are the Symptoms of Intracranial Hemorrhage?

The symptoms of brain hemorrhage depend on the type and location of the bleeding. The common symptoms include:

1. Sudden numbness, tingling, or paralysis on one side of the body (arm, leg, or face).

2. Dizziness.

3. Sudden severe headache.

4. Vomiting and nausea.

5. Seizures.

6. Difficulty in breathing.

7. Confusion.

8. Abnormal heart rate.

9. Difficulty in seeing (loss of vision).

10. Difficulty in understanding speech, reading, and writing.

11. Lack of energy.

12. Stiff neck.

13. Sensitivity to light.

14. Slurred speech.

15. Sleepiness.

16. Reduced consciousness or unconsciousness.

17. Coma.

What Are the Diagnostic Tests Performed for Intracranial Hemorrhage?

Intracranial hemorrhage is diagnosed based on the following:

• The patient’s symptoms.

• Imaging scans such as:

  • Computed tomography (CT).

  • Magnetic resonance imaging (MRI).

  • Magnetic resonance angiogram (checks blood vessels and blood flow).

• Other tests:

  • Electroencephalogram (to check brain activity).

• Spinal tap (to check the cerebrospinal fluid surrounding the brain).

• Conventional angiography (to identify any blood vessel or wall abnormalities).

• Chest X-ray.

• Blood tests (specific blood tests to assess the cause, to check for blood sugar levels, and to check if the blood has normal clotting factors).

• Urine tests.

What to Do if Intracranial Hemorrhage Is Suspected in a Person?

Intracranial hemorrhage is a medical emergency that requires prompt analysis and treatment. If a person experiences severe head injury or displays symptoms of intracranial hemorrhage, seek emergency medical help immediately. Rupture of blood vessels can lead to stroke. The brain cells get damaged due to oxygen and nutrition depletion and begin to die within minutes if treatment is not initiated. If someone may be having intracranial hemorrhage or stroke, do the following:

• Quickly assess the patient.

• Call for emergency medical services. In case one person is experiencing the symptoms, get help and ask someone else to call for help.

• It is preferred to call an ambulance to get to the hospital. Do not drive the patient in one’s car. The emergency medical personnel start life-saving medical interventions and treatment on the way to the emergency department. They also ensure that the hospital is well-equipped with the medications and treatments to handle the patient on arrival.

• Stay calm and focused until emergency help arrives.

• It is important to note the time when the symptoms started. This is crucial, especially in stroke patient management.

• Make sure the patient is in a safe and comfortable position. The patient can be made to lie down (on one side) with the head slightly raised (to prevent aspiration of vomit and other secretions) and well-supported.

• Check the patient’s breathing, airway, and circulation (blood flow in the body). If the patient has breathing difficulty, loosen any tight clothing (scarf, tie). Check if the patient’s airway (air passage to the lungs) is clear. If the patient is not breathing, initiate cardiopulmonary resuscitation (repeated chest compressions and rescue breathing) to ensure blood flow to all body parts.

• Reassure the patient in a calm and soothing voice.

• If the patient is cold or if the patient’s body temperature is dropping, cover them (with a blanket) to keep them warm.

• Do not give the patients anything to drink or eat.

• Do not move the person, especially if the person is showing any weakness in a limb.

• Carefully observe the patient for any worsening of symptoms. Be prepared to inform the emergency personnel about the patient’s symptoms and signs and when they started.

How Is Intracranial Hemorrhage Managed?

The cause of the bleeding in the brain is first determined so that the patients can be appropriately managed. The patients are usually admitted to an intensive care unit. They are continuously monitored, and vital functions (such as breathing) are supported as needed and treated. Intracranial hemorrhage is managed based on the cause, bleeding's size, location, severity, and other general factors.

What Are the Interventions Done for the Treatment of Intracranial Hemorrhage?

Listed below are the interventions done to treat intracranial hemorrhage:

Surgical Interventions:

• Bleeding causes blood pooling in the brain and its cavities, which leads to increased pressure in and around the brain. This pressure is relieved (decompression of the brain) by various surgical procedures such as the following:

  • Burr Hole Surgery - A hole is drilled in the skull to let the blood drain out and relieve pressure.

  • Craniectomy Incision - The skull is partially removed to relieve pressure.

  • Craniotomy Surgery - The skull is opened to relieve the intracranial pressure.

• Minimally invasive surgeries.

• In case of weak blood vessels or aneurysms, surgery is done to isolate, block off, or support the walls of the blood vessels to reduce the risk of fatal bleeding.

• Surgical clipping or sealing off of the blood vessel malformations.

• Endovascular coiling and stenting to manage weak blood vessels or aneurysms (invasive procedures to insert coiled wires or tubes to ensure smooth blood flow).

• Angiography-type procedures to prevent future rupture of the blood vessels.

• Computer-guided radiation to seal off blood vessel malformations (to stop bleeding).

Medications:

• Medications to control blood pressure.

• Anti-anxiety medications.

• Medications to prevent or control seizures (anti-epileptic drugs).

• Medications to manage blood sugar levels.

• Painkillers to manage severe headaches.

• Medications to relieve specific symptoms.

• Fluids and nutrients are administered intravenously (through the vein). If the patient has difficulty swallowing, a feeding tube (gastronomy tube) is used to ensure sufficient nutrition.

• If patients taking anticoagulants (drugs to prevent clotting) have a stroke due to the bleeding (a hemorrhagic stroke), treatment to help their blood clot is initiated. These include:

  • Intravenous administration of Vitamin K.

  • Platelet transfusion.

  • Transfusion of fresh frozen plasma (blood without blood cells and platelets).

  • Prothrombin (clotting factor) complex concentrate that contains clotting factors and other proteins that help the blood to clot is given.

Conclusion:

Bleeding in and around the brain is life-threatening. It requires emergency treatments initiated on time. Intracranial hemorrhage can occur in different parts of the brain, its membranes, brain cavities, and the space between the skull and brain. The treatment depends on the bleed's cause, type, severity, and location. These include minimally invasive procedures, medications, and surgical procedures. If a person has intracranial hemorrhage symptoms due to a blow or accident, immediately call for medical help. Treatment on time prevents permanent disability and death due to brain damage.