Treatment of brain haemorrhage: drugs or neurosurgery?

How are spontaneous types of hemorrhage treated?

The aim of treating intracerebral haemorrhage is to prevent further growth of the haematoma and stop the bleeding.

Early treatment will prevent complications and late sequelae of bleeding.

Therapy consists of correcting blood pressure with antihypertensive drugs. In an attempt to rapidly lower the pressure, intravenous hypotensive agents, such as urapidil, are administered. Continuous monitoring of blood pressure at the patient's bedside is necessary.

In addition, attention is focused on haemostasis and modification of haemocoagulation(blood clotting).

In bulky cerebral oedema, anti-haemorrhagic therapy, specifically intravenous mannitol, is in order.

Proper patient positioning is also important. The head should be 30-45° higher than the rest of the body.

In some cases, the patient does not respond to treatment, his clinical condition progresses and his consciousness deteriorates. It is necessary to put him into artificial sleep with connection to artificial pulmonary ventilation.

Neurosurgical treatment is performed with the aim of draining large haematomas outside the basal ganglia with a volume of 30-100 ml. This procedure will rapidly reduce intraluminal pressure and reduce the risk of ischemia around the hemorrhage.

Surgical treatment may save the patient's life but will not improve the residual neurological deficit.

Initial treatment of a patient with a subarachnoid hemorrhage includes absolute bed rest. It is recommended to be in a quiet, dark room with the head propped up.

Damping of severe headaches is achieved by administering analgesics and anxiolytics (drugs against psychological restlessness and anxiety). Antiemetics (anti-vomiting drugs) may be given. Epileptic seizures are prevented by giving, for example, phenytoin.

Particular attention is paid to blood pressure control. An ECG is performed to detect and treat cardiac arrhythmias early.

After a correct diagnosis and detection of a ruptured aneurysm, neurosurgical treatment is indicated . It is designed to remove the aneurysm from the circulation.

Two neurosurgical approaches are possible. The surgeon decides on the specific procedure:

1. cutting the neck from the outside of the aneurysm with a neurosurgical clamp
2. intravascular treatment of the aneurysm using a coil inserted inside the aneurysm to fill the sac. This is called coiling

Currently the aim is to operate on the aneurysm within 48 hours of it bursting. At that time, patients have not yet shown reflex narrowing of the blood vessels (spasms).

The goal of rapid surgery is to prevent rebleeding and ischemic brain damage due to vasospasm.

The goal of medical therapy is to reduce the risk of rebleeding, minimize spasm and prevent complications.

Treatment after trauma

The primary treatment for epidural bleeding is emergency neurosurgery.

After draining the hematoma, the source of the bleeding and any skull fractures are treated. A hard diaper is sutured to the skull bones to prevent further bleeding.

In epidural bleeding caused by bleeding from a vein or venous plexus, the hematoma may not enlarge rapidly and expansively. In such cases, conservative treatment without the need for surgical intervention is also an option.

However, it is necessary to monitor the patient with repeated CT scans of the brain until the hematoma is healed.

Surgery is also the treatment of choice for acute subdural haematoma. The blood content is drained through a hole drilled in the skull.

In extensive brain swelling with displacement of brain structures, more extensive neurosurgical intervention is required.

A so-called decompressive craniectomy is performed. Part of the bone is removed so that the swollen brain is not compressed in the small space of the skull. Once the brain has returned to its position and the swelling has gone down, this piece of bone can be put back in place.

Chronic subdural hematoma is treated with continuous 24-hour drainage (gradual draining of the contents). Sometimes chronic hematomas are wrapped with a connective tissue sheath. In this case, a craniectomy is again performed and the hematoma and sheath are removed.