The term "brain haemorrhage" as used here means a sudden and spontaneous accumulation of blood in or around the brain. Bleeding occurring as a result of an accident will not be discussed here.

1. Causes

Spontaneous brain haemorrhages can be of two kinds:

  • Bleeding in the brain, also called intracerebral bleeding
  • Bleeding around the brain, called subarachnoid and subdural bleeding

1.1. Intracerebral bleeding

Bleeding within the brain tissue can be classified in two categories:

  • Bleeding "without a cause"
  • Bleeding "with a cause"

1.1.1 Bleeding "without a cause"

Of course such bleeding does indeed have a cause of some kind, which is why we are placing the concept within quote marks. However, with this kind of bleeding it is not possible to indicate a cause by means of closer examination, which means surgery is not always appropriate in these cases.

hersenbloeding 'zonder oorzaak'

Victims of this type of bleeding are usually older patients (65 years and older) with a prior history of high blood pressure, diabetes, indications of arteriosclerosis or hardening of the arteries, or a combination of these conditions. Bleeding occurs suddenly and is mostly located deep in the brain, in an area referred to as the "basal ganglia". Virtually always this type of bleeding will result in paralysis of one side of the body on the side opposite to that of the brain in which the bleeding occurred, and usually there is some degree of loss of consciousness. Treatment is usually carried out by a neurologist; only rarely is surgery required. Only when there is loss of consciousness due to the pressure of the bleeding onto the adjacent brain can a brain operation be taken into consideration. Either a catheter is placed in one of the brain ventricles in order to keep the pressure in the brain under control, or the blood clot itself is removed.

1.1.2. Bleeding "with a cause"

This type of bleeding, too, occurs suddenly, but differs from the previous category in that it usually occurs in younger patients and is located much closer to the surface of the brain. In this type of bleeding a three-dimensional reconstruction of the blood vessels is made by means of a CT scan (see Illustration) in order to determine whether the cause could be an anomaly of the blood vessels.

There are two significant types of anomalies:

Arteriovenous malformation (AVM) Which is like a tangled ball of arteries and veins. These malformations already occur very early in the pregnancy (in the 2nd to 3rd week), when the vascular system starts developing. They are therefore present from the very beginning and in the course of the person's life can give rise to a brain haemorrhage. Another way in which they can be discovered is due to an epileptic seizure. Alternatively, they can go completely unnoticed. Approximately three quarters of all cases are operable: the remainder is either located so deep inside the brain or is so large or difficult to access that surgery would be impossible without causing significant damage to normal tissue. In those cases, a special type of radiation may be a possibility. An AVM can also be invisible on an angiography, but visible on a CT scan or MRI.

Arteriovenous malformation (AVM)

Aneurysms. An aneurysm is another congenital abnormality of a blood vessel, in particular of an artery. Although bleeding usually occurs around the brain, bleeding in the brain tissue itself can also occur due to a burst, or ruptured, aneurysm.

aneurysma

1.2. Subarachnoid bleeding

A subarachnoid haemorrhage is sudden bleeding occurring around the brain. This type of bleeding will almost always be the result of a ruptured aneurysm. An aneurysm is a ballooning or a sac-like dilatation of the wall of an artery in the brain. There are some typical places in which aneurysms primarily occur, but in principle they can occur anywhere. The weakness is congenital; the aneurysm itself probably develops slowly throughout a person's life. Factors promoting the formation of aneurysms include high blood pressure and arteriosclerosis, or hardening of the arterial walls. This condition, in turn, is aggravated by factors such as high blood pressure, diabetes, smoking, and a high blood cholesterol level.

1.2.1. Incidence, signs and symptoms

Subarachnoid haemorrhages mostly occur around the ages of 40 to 50. The symptoms are a very sudden, intense headache accompanied by pain in the neck. Many patients describe a sort of "crack" or "snap" in the neck. Approximately 25% of all patients die fairly quickly as a result of the haemorrhage. For those where the bleeding stops, the situation can differ widely between full recovery and a deep coma.

Unfortunately, this type of bleeding is not always recognised for what it actually is. Especially when patients complain only of a headache or pain in the neck, the first thought is of a migraine, and the patient is sometimes even referred to a physiotherapist. On average, each year this type of bleeding affects 5 out of every 100,000 people in this country, so that GPs will only see approximately one case every 8 years. This relatively low frequency of occurrence translates to relatively low diagnostic experience.

1.2.2. Examination

Once the patient is admitted to the hospital, the first examination that will be carried out will be a CT scan to confirm the presence of bleeding in or around the brain. Sometimes it can become necessary also to introduce a needle into the lower spine (lumbar puncture) to determine whether there is blood in the cerebrospinal fluid, which is equally conclusive evidence. Especially with bleeding that has happened some time ago, the CT scan can be "clean" if all the blood has dissolved. The cerebrospinal fluid (the liquor), however, remains yellowish for a longer period of time as a result of blood breakdown products.

The final proof of the diagnosis is provided by an angiography (an examination of the blood vessels) of the brain, but nowadays the initial CT scan can also provide sufficient information. All blood vessels in the brain are examined in the angiography, as in approximately 15% of all cases more than one aneurysm can be involved.

1.2.3. Treatment of brain aneurysms

It is not always necessary to treat brain aneurysms. In certain cases, (in particular when treatment of the aneurysm would impair important brain functions) treatment may even be contraindicated. There are different factors that play a role in the decision as to whether or not to treat a brain aneurysm, as well as in regard to the moment at which treatment should take place. These factors include the patient's health status and condition, age, location of the aneurysm, its size, the potential risks involved in the treatment, and, of course, the patient's own wishes. In view of the fact that most brain aneurysms present as a brain haemorrhage, treatment is often aimed at preventing future bleeding.

This is why in most cases doctors will try to close the aneurysm.

This can be accomplished in different ways:

Direct closure of the aneurysm:

Surgery. By means of an opening in the skull, the aneurysm is approached directly and a small clip is placed on the neck of the aneurysm so that blood supply to the bulging section is closed off. Placing the clip is called "clipping". (See video)

Directe aneurysma afsluiting

Illustration 1: On the left, an image of an aneurysm with a clip placed over the neck.

As soon as this is accomplished, no further bleeding can originate from that aneurysm. If during the operation it does not seem possible to clip the aneurysm (e.g. because otherwise important brain arteries would also be closed off at the same time) it is possible to try to "wrap" the aneurysm. A material (for example, pieces of cotton) is wrapped around the aneurysm, causing scarring to develop around it, thus thickening and strengthening the aneurysm wall. This reduces the risk of repeat haemorrhaging.

Endovascular treatment:

This treatment is relatively new and has been in development over the last few years. Its principle is that by means of a small tube inserted in the femoral artery the aneurysm is filled from the inside with a small balloon or a small platinum spiral, called a coil, or with a kind of glue. The placing of coils (or "coiling") is always easier, and nowadays this technique is also applied more and more frequently in our own clinic (Illustration y).

Endovasculaire behandeling - coiling

Another aneurysm treatment method is coiling. In this procedure, a vascular catheter is introduced into the femoral artery and directed to the mouth of the aneurysm. Small platinum spirals are then directed into the aneurysm through this guide catheter; once in the aneurysm, they coil up and entirely fill the cavity, thus closing it off from the blood supply and preventing new bleeding.

The advantage of the endovascular treatment is that brain surgery becomes unnecessary. The disadvantage of this approach is that sometimes it is not possible to close off the aneurysm completely and definitively by means of coils in one single procedure, so that regular follow-up imaging (angiography) and sometimes several treatments will be necessary. The long-term efficacy of endovascular treatment of a brain aneurysm is not yet known. The goal of aneurysm treatment is to prevent new haemorrhages. It is known that certain "coiled" aneurysms, although originally completely filled up, have partially opened up again after a certain period of time. This is due to compacting of the coil mass. In such cases, additional treatment will be required. In some cases, this can be additional coiling, but in certain other cases surgery may become necessary. This means that patients having undergone one coiling will often have to be followed over a long period of time, and will sometimes have to undergo several blood vessel examinations. The choice of treatment always depends on the patient's individual situation. This is always "made to measure" custom work to be decided upon by the neurosurgery and neuroradiology teams. It is never possible to tell in advance whether the treatment will be successful.

Indirect closure of the aneurysm:

Sometimes it becomes evident that a direct closure of the aneurysm is not possible. Then doctors can try to close off the supplying blood vessel (also called the "mother vessel") in which the aneurysm is located. This is possible only if blood supply to that part of the brain can be taken over by other cerebral arteries. Obviously this must be determined beforehand. The artery can be closed off surgically by placing a small ring around the carotid artery and to close it slowly over several days from the outside, until the blood vessel is completely closed off. In the meantime, the blood supply to that part of the brain can be taken over by other arteries of the brain. Currently, mother vessel closure is ever more frequently carried out through the femoral artery (as an endovascular procedure). A small balloon is pushed into the targeted blood vessel, and inflated once it has arrived at the correct place. This blocks up the blood vessel, impeding any further blood flow. The little balloon is then disconnected, so that it remains in the mother vessel in its inflated state. The goal of this procedure is to stop blood supply to the vessel and the aneurysm, so that no further bleeding can originate from it.

Another alternative is to perform a diversion around and past the aneurysm, creating a bypass through which oxygen-rich blood can be delivered to the relevant part of the brain. This procedure is usually followed by closing off the blood vessel filling the aneurysm. The consequence of the closure is then also a hermetic coagulation of the aneurysm.

1.2.4. Treatment risks

The risks involved in the treatment of brain aneurysms depend on the size and location of the aneurysm, the disorders caused by the aneurysm (e.g. whether there has been bleeding, or a heart attack), on the patient's age and neurological and physical condition, on the type of therapy selected, etc.

In addition to general complications such as infections (e.g. wound infection, pneumonia), blood discharge or extravasation, thrombosis, etc., there are also specific complications related to the bleeding itself and the treatment of the brain aneurysm. Among others, such complications can include recurring brain haemorrhage (either even before the treatment could be started, or during the treatment itself, i.e. while attempting to close off the aneurysm), a brain infarction (for example as a result of cramping of the blood vessels (spasm) or by (unintended) closure of a blood vessel at the moment when an aneurysm is clipped or coiled), or a swelling of the brain (e.g. due to manipulation of the brain while accessing it through the skull) or cerebrospinal fluid drainage disorders. The consequence could be paralysis or other permanent (deficit) symptoms in connection with the brain or brain nerves (aphasia: the inability to generate or comprehend spoken or written language or epilepsy, unconsciousness, or coma). Recurring bleeding or brain infarction can damage the brain to such an extent that the patient may die. Especially in patients who have suffered bleeding from an aneurysm, their condition in the first two weeks following the haemorrhage is often critical. Even if doctors succeeded in closing off the aneurysm shortly after the haemorrhage, there can still be sequels of the condition, in particular in the form of cramping of the blood vessels (called vasospasm). Development of vasospasm is (besides a bleeding recurrence) the greatest risk for a patient after aneurismal brain haemorrhage. The risk of vasospasm is greatest in the period between the 4th and the 10th day following the brain haemorrhage. Vasospasm can bring about a serious (and not seldom fatal) deterioration of the patient's condition, even if the aneurysm has been operated on. Even infusion and drug therapy, and, if necessary, artificial respiration in the Intensive Care Unit have only limited effect on vasospasm. Treatment involving the use of a catheter and a small inflatable balloon that is pushed into the cramping blood vessel, thus stretching it out, is still in its infancy. Perhaps this will open up new possibilities for the treatment of vasospasm in the future.

1.2.5. Recovery after aneurysm treatment

Patient recovery after treatment of a brain aneurysm is strongly dependent on the starting situation. A patient having shortly before suffered an aneurysmal brain haemorrhage will generally spend several months in recovery. Of course, this depends on the extent of the brain damage caused by the haemorrhage, and on whether there has been any severe vasospasm. Following aneurysmal bleeding, many patients suffer from irritability, lack of concentration, forgetfulness and headache. This can mean that the patient will no longer be able to return to his or her previous professional occupation. Sometimes there are personality or character changes, or distinct neurological disorders such as paralysis or aphasia (problems with the ability to speak due to damage to the language centre in the brain). In certain cases admission to a rehabilitation centre will be necessary, combined with intensive care on the part of physiotherapists, speech and language therapists, occupational therapists, psychologists and a doctor specialising in rehabilitation. Fortunately there are also patients who recover without residual symptoms and who after some time continue to function as before.

1.2.6. Subdural bleeding

This type of bleeding takes place between the hard membrane enveloping the brain (called the dura mater) and the brain and is actually a little outside of the scope of this section, as this type of haemorrhage is usually the result of an accident.

There are two subtypes:

Acute subdural haematoma:

This normally occurs as a direct consequence of a usually serious accident involving head injuries. The tearing of arteries can cause a small blood puddle that can be identified by means of a CT scan. Mostly, this does not require surgery. The prognosis for an acute subdural haematoma is very poor. There is always much more involved than the blood puddle itself.

Het chronische subdurale hematoom

Chronic subdural haematoma

This usually occurs in older people, and has to do with the reduction in the amount of brain tissue that is a normal part of aging. Frequently (sometimes upon questioning) people will report a small, unimportant accident, as could be knocking one's head against a window frame or an open car boot lid. In fact, many patients cannot remember an accident at all. The clinical picture develops slowly and can consist of drowsiness, confusion, speech and comprehension disorders, sometimes also hemiplegia (paralysis of one side of the body). The symptoms can look a lot like dementia, a condition also seen in older people. A CT scan enables correct diagnosis of the problem. (See Illustration)

Treatment consists in drawing off the extravasation by means of small orifices in the skull. If a thick capsule has formed, it has to be removed via an opening in the skull. The symptoms are sometimes bilateral (they appear on both sides of the body). The prognosis is very good