Brain Hemorrhage

Summary

• Bleeding inside or around the brain is called brain hemorrhage.
• Brain hemorrhage is caused by hypertension, drug abuse, aneurysm, trauma, blood vessel disorders, liver diseases, and brain tumors.
• Brain hemorrhages may be of several types like subarachnoid, subdural, intraparenchymal and epidural hemorrhage.
• Symptoms include nausea, headache, swelling on face, etc., however, suitable tests like CT scan, MRI, angiogram, etc. should be done for precise diagnosis.
• Treatment of brain hemorrhage includes surgeries to remove clots and drugs to prevent spasms and seizures.
• Brain hemorrhages may be prevented by preventing traumatic accidents and maintaining a healthy lifestyle.

Brain hemorrhage also known as intracranial hemorrhage or brain bleed refers to bleeding in or around the brain. It is a condition of medical emergency that requires immediate treatment.

Brain hemorrhage can quickly cause damage and compression of the brain tissue. The extent of damage depends on how early bleeding in controlled. Bleeding can disturb normal circulation such that brain is deprived of oxygen, leading to stroke.

CAUSES

Bleeding of brain occurs due to
following reasons:

Hypertension

Hypertension or high blood pressure may cause small arteries in the brain to burst that causes bleeding inside the brain. Hypertension is a significant risk factor for stroke. Chronic hypertension is one of the leading causes of intracerebral hemorrhage.

Often hypertension causes so much bleeding that blood spills into the ventricles of brain causing intraventricular hemorrhage. This condition results in fatal condition of hydrocephalus (Okkumura et al. 2005).     

Drug abuse

Drugs like cocaine and alcohol may increasingly causing brain hemorrhage in young adults. It is believed that drug addicts have vascular malformations that lead to brain hemorrhage.

Intracranial aneurysms and arteriovenous malformations have been observed in drug addict patients who come to hospital having intracerebral hemorrhage (Mcevoy, Kitchen and Thomas, 2000).

Aneurysm

It refers to weakened artery wall that creates bulge or distention in a brain artery that ruptures. This rupture leads to bleeding into the brain in the subarachnoid region and therefore known as subarachnoid hemorrhage.

Aneurysms usually occur at the branch points of arteries and enlarge slowly. However, as they grow in size, the balloon stretches leading to its weakening. In some cases aneurysms leak slightly that causes a sudden severe headache.

This slight leakage is usually followed by a severe rupture and bleeding. The reason for leakage of aneurysms may be due to high blood pressure, heavy lifting and even strong emotions (stress or anger). Most of the people develop aneurysms after the age of 40.

Aneurysms vary in shape, location and size. Once an aneurysm has bled, the chance of re-bleeding greatly increases.   

Trauma

Accidents or injuries cause trauma that may leads to bleeding in the brain. In infants, birth injuries or blunt force trauma to pregnant woman’s abdomen may cause brain hemorrhage in the baby.

Blood vessel disorders

Tangling of blood vessels, also known as, arteriovenous malformation (AVM), may cause brain hemorrhage. Arteries carry oxygenated blood to the brain while veins carry deoxygenated blood from the brain to the lungs. AVM disturb this process of blood flow. Exact causes of AVM formation are not known.

Some people may inherit them in their genes; some are born with then while others develop them later in their life. AM puts pressure on the walls of veins and arteries and make them weak. T

herefore, the affected arteries can rupture causing bleeding in the brain (Solomon and Connolly, 2017). 

Amyloid angiopathy

It refers to buildup of amyloid protein in the walls of arteries that puts pressure on arteries during blood flow. This results in increased risk of bleeding inside the brain and leads to the development of subarachnoid hemorrhage and other hemorrhagic lesions.

Further complications of amyloid angiopathy include dementia and Alzheimer’s disease. Amyloid protein is normally not deposited in other parts of the body and its risk of deposition in brain increases with increasing age (Yamada, 2013).   

Brain Tumors

Tumors like angiomas that are highly vascular and metastatic tumors can cause bleeding in the brain. The highest rate of hemorrhage from primary brain tumors have been observed in patients suffering from pilocytic astrocytomas.

On the other hand, the highest rate of hemorrhage from secondary tumor has been observed in patients suffering from hepatocellular carcinoma and thyroid papillary carcinomas (Lieu et al. 1999).     

TYPES

There are several types of brain hemorrhages that depend on the
location of bleeding.

• Subarachnoid hemorrhage: It is the bleeding that
  occurs between the brain and membranes covering the brain. It may be traumatic
  or non-traumatic (aneurysmal and non-aneurysmal) hemorrhage. When aneurysmal
  ruptures, it may cause bleeding into the subarachnoid space called aneurysmal
  subarachnoid hemorrhage. On the other hand non- aneurysmal subarachnoid
  hemorrhages do not have identifiable aneurysms and may be caused by sudden
  acceleration changes to the brain.   
• Subdural hemorrhage: It occurs above the
  brain but below the dura layer. This type of hemorrhage mostly occurs when a
  vessel between the brain and skull is stretched often due to a blunt head
  injury or penetrating head injury.
• Epidural hemorrhage: It is the hemorrhage
  that causes bleeding in the space between dura and inner table of the skull. It
  may be due to rupture of a vein or an artery. It is mostly caused by damage to
  middle meningeal artery that is present below the temporoparietal area of the
  skull. Venous epidural hematomas are mostly common in pediatric patients.   
• Intraparenchymal
  hemorrhage:
  It refers to bleeding in the brain parenchyma. It may be caused by
  hypertension, tumors, infections, coagulopathy etc. It is responsible for
  10-20% of stroke cases and mostly observed in older people who are above the
  age of 55 (Tenny and Thorell, 2019).  

SYMPTOMS

Symptoms of brain hemorrhage
include nausea, vomiting, headache, fever, difficulty in speaking, loss of
consciousness, problems in vision, weakness, difficulty in swallowing, sudden
tingling in arms or legs and problems in maintaining balance. Symptoms of brain
hemorrhage should be addressed as quickly as possible to prevent permanent
brain damage.

DIAGNOSIS

Some of the brain hemorrhages do not require treatment and go away on their own. However, if the symptoms of brain hemorrhage are found in the patient, other tests like CT scan or MRI are advised.

In addition, other tests like angiogram, computed tomography (CT) scan or cerebrospinal fluid (CSF) exam may also be advised. During angiogram, a catheter is allowed to enter the artery and dye is inserted that reaches the brain. Then X-ray images of brain are taken in which the dye helps to show any ruptured blood vessels.

For CT scan, dye is allowed to enter the blood stream that allows the CT scan to produce pictures of all arteries in the brain. Brain hemorrhage allows RBCs to reach the CSF. Therefore, presence of blood in CSF may be tested through lumbar puncture. In a lumbar puncture, a needle is inserted to remove the spinal fluid that is used for testing (Heit, Iv and Wintermark, 2017).

TREATMENT

Severe brain hemorrhages require surgeries to prevent blood loss and avoid building pressure in the brain. During surgeries, blood is drained from the brain or the ruptured parts of brain are repaired. Craniotomy is a surgical treatment in which a hole is drilled into the skull and blood clot is removed.

In some procedures, surgeons remove the blood clots through a dime-sized port or channel. This kind of surgery produces lesser scarring, quicker recovery and fewer post-surgery complications as compared to open surgeries (Mendelow, 2016).

Drugs recommended for brain hemorrhage include nimodipine that prevents artery spams, phenytoin and related medicines for preventing seizures, drugs for controlling blood pressure, anti-anxiety and painkillers and laxatives for preventing bowel movement related strains. Administration of Factor VIIa within four hours helps to prevent bleeding and clot formation.

Corticosteroids are given to reduce swelling. Usually, brain hemorrhage affected children recover better than adults because children’s brain is still developing. Rehabilitation involves speech and physical therapies to bring the patient back to normal life as much as possible.   

PREVENTION

In order to prevent brain hemorrhages, risk factors should be avoided. For example, wearing helmets while riding bikes, care during physical sports or use of seat belts may prevent traumatic brain injuries.

In addition, changes in lifestyle like healthy eating, no smoking, regular exercise and avoiding addictive drugs greatly decrease the chances of brain hemorrhages.  

In a recent study, it has been found that the drug statins that are recommended for the treatment of cardiovascular diseases may also prevent brain hemorrhages. Although, it was generally believed that blood thinners increase the risk of brain hemorrhage. Nevertheless, this study revealed the opposite scenarios.

This study involved a large group of people (519,800) during a time period of 2004-14 who used statins and compared them with a control group who did not take statins.

It was found that the risk of brain hemorrhage was 25-35% lower in people who were taking statins. However, further studies are required to confirm these findings.

CONCLUSION

It is concluded that brain hemorrhages can lead to serious health effects and maybe even fatal. Brain hemorrhages can be prevented by avoiding risk factors. In the case of brain hemorrhages, early diagnosis and treatment may prevent severe health effects or death.

REFERENCES

1. Heit, J.J., Iv, M. and Wintermark, M., 2017. Imaging of intracranial hemorrhage. Journal of stroke, 19(1), p.11.
2. Mcevoy, ND Kitchen, DGT Thomas, A.W., 2000. Intracerebral haemorrhage and drug abuse in young adults. British journal of neurosurgery, 14(5), pp.449-454.
3. Mendelow, A.D., 2016. Surgical craniotomy for intracerebral haemorrhage. In New Insights in Intracerebral Hemorrhage (Vol. 37, pp. 148-154). Karger Publishers.
4. Okumura, K., Ohya, Y., Maehara, A., Wakugami, K., Iseki, K. and Takishita, S., 2005. Effects of blood pressure levels on case fatality after acute stroke. Journal of hypertension, 23(6), pp.1217-1223.
5. Solomon, R.A. and Connolly Jr, E.S., 2017. Arteriovenous malformations of the brain. New England Journal of Medicine, 376(19), pp.1859-1866.
6. Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2019 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470242/
7. Yamada, M., 2013, November. Brain hemorrhages in cerebral amyloid angiopathy. In Seminars in thrombosis and hemostasis (Vol. 39, No. 08, pp. 955-962). Thieme Medical Publishers.