INTRACEREBRAL HEMORRHAGE
For the families of intracerebral hemorrhage victims, the following scenario
will sound familiar, almost like a dramatic scene from a TV movie.
It begins at a wedding reception. Grandfather is dancing with the bride,
his beloved granddaughter. Everyone is having such a good time! He is returning
to his table to be with Grandmother when he emits a cry and collapses.
Loved ones rush to his aid and, for a moment, he seems to be coming out
of it. Then, all notice his speech is not normal; he cannot get up, even
though he tries. The right side of his body isn't working at all.
An ambulance rushes him to the hospital. Everyone looks worried. In
the emergency room, the CAT scan tells the physicians that he has suffered
a serious "Brain Attack"/Stroke. A tiny blood vessel has burst and bled
under high pressure. It leaves a path of destroyed brain tissue in its
wake and further threatens surrounding brain tissue with more damage, as
the mass effect of the large volume of blood compresses the surrounding
brain tissue.
The hospital learns of his high blood pressure history.
This is the awful world of the hypertensive "Brain Attack."
EXPLAINING WHAT HAS HAPPENED
The brain is an "end organ." It is also the most energy-hungry organ
in the body. Because of these two factors, it constantly demands a disproportionately
large percentage of the blood supply from the heart. The brain weighs about
5% of the body's total weight, but constantly uses more than 20% of the
body's blood supply to survive. It has both "old parts" and "new parts."
As the human species evolved over the ages, some of the less sophisticated
parts of the brain remained unchanged; other parts have been modified as
humankind progressed along its evolutionary path. Among these unchanged
brain parts are the very simple, thin-walled blood vessels that supply
one of the oldest parts of the brain, the basal ganglia. This area of the
brain is made up of the neurons responsible for things like control of
coordination and central relay centers for sensation. (Globus pallidus,
thalamus, etc. are parts of the brain which are affected by Parkinson's
Disease). Of all the vessels in the body, these are the least prepared
to handle chronic, increased blood pressure. At the same time, they are
responsible for carrying a larger amount of blood to a very vital area,
at relatively high pressures. Thus, over the years, they can develop microscopic
outpouchings called Charcot aneurysms. These are not at all like cerebral
aneurysms which cause subarachnoid hemorrhage (SAH). When the tiny Charcot
outpouchings burst, blood enters into the brain at very high pressure,
destroying all tissue in its path.
Other Kinds of Intracerebral Hemorrhages
Other hemorrhages include those arising from: arteriovenous malformations,
unsuspected tumors, brain vessel diseases due to infection, degnerative
diseases such as amyloid angiopathy, drug useage (intravenous, amphetamine
or cocaine usage), or blood thinner therapies (e.g. coumadin or heparin
treatment for heart disease).
Changing Times, Changing Therapies
Until recently, ICH had been treated with watchful waiting, except for
those cases where the size of the hemorrhage absolutely demanded surgery.
The brain will eventually absorb the blood over time (three weeks to 2
months). With the advent of improved surgical techniques, localizing imaging
capabilities, and better understanding, a move to early surgical removal
or decompression has been the new trend.
Better Understanding
Even if the high pressure blood hadn't cut a path of brain destruction,
the shear mass of the blood within the brain and the tight confines of
the skull could be responsible for continuing damage to surrounding brain
tissues. In this surrounding brain (called the pneumbra), the local pressure
of a blood clot may be greater than that of its blood supply, causing the
brain cells in that area to die off. To minimize further destruction, therefore,
it makes sense to reduce the local pressure by decompressing such brain
tissues through the removal of most of the blood clot.
Also, it is now known that blood becomes toxic. Blood cells are tiny
packages of chemicals that the body is normally protected from by the cell
membranes that contain them. As the blood cells within a clot die, they
swell, burst, and release toxic chemicals which are capable of damaging
the surrounding brain. The new approach to this problem is to eradicate
such toxins BEFORE they are released.
Improved Imaging Capabilities
No matter how deep and unseen the blood clot, new imaging techniques
allow the surgeon to target and see exactly where he needs to go when removing
a blood clot. Sterotactic machinery and real-time intraoperative ultrasound
guidance systems have helped tremendously, practically eliminating the
downside of surgery.
Improved Surgical Techniques
Smaller openings, better surgical accuracy, improved lighting, the simplicity
of needle aspiration techniques, and the usage of surgical hemostatic agents
(that prevent post operative bleeding) all lessen the danger of brain surgery
for ICH. It is now reasonable to remove any and all brain hemorrhages of
significant size very soon after the patient has arrived at the hospital.
This new approach has become a part of the "acute care" treatment application
to Brain Attack victims. Over the past few years, the medical community
has come to consider ICH a near emergency and treated as such. Your neurosurgeon
or neurologist will explain "acute care" treatment early, in the hopes
of salvaging undamaged brain when possible.
Delay or Hold on the Surgery
Factors that might delay early removal of an ICH include: stabilization
of blood pressure or other medical conditions (e.g. diabetes, clotting
abnormalities, liver or kidney failure, heart problems etc.); reversal
of medications that prevent blood clotting (e.g. coumadin or aspirin),
or Amyloid Disease of the brain. Most often, surgery is not helpful in
these instances, and future blood clots could also occur after a relatively
short interval. Another condition calling for surgical delay could be the
extremely poor neurologic state of the patient. Even a small hemorrhage
in the wrong place (such as the middle of the brainstem) may be associated
with such a poor outlook that surgery would not be of help, or could even
result in further damage.
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