Surgery

Overview of Intra Cranial Bleeding



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Intra-cranial bleeding refers to a bleeding or a hemorrhage that takes place inside the skull. Depending on the site of the bleeding, it can be either extra cerebral or else intra cerebral.

Extra cerebral or extra-axial bleeding

The bleeding or hemorrhage that is taking place would not be within the brain substance but will be either outside or within the brains covering layers. These hemorrhages are most often well demarcated and will have a higher level of prognosis if timely interventions are met. There can be three different kinds of extra-axial bleeding taking place in the skull. These would be:

* Extra-dural hemorrhage: In this condition the bleeding takes place outside the brain covering between the skull bone and the tissues. The most likely reason would be a trauma to the skull which will give rise to a damaged blood vessel. Most often, the middle meningeal artery would be affected and thus the bleeding can become heavy.

* Sub-dural hemorrhage: The bleeding that takes place in this condition would be confined to the sub-dural space which is the space that is formed when the two layers, the dura and the arachnoid, are separated. The bleeding could be the result of lacerated bridging vessels that is present across this space.

* Subarachnoid hemorrhage: Probably the condition with the most characteristic presentation, the subarachnoid hemorrhage would result in a ‘thunder clap’ headache which occurs suddenly from no where. The bleeding can be the result of ruptured aneurysms or else arteriovenous malformations. It occurs between the meningeal layers and the arachnoid layer and thus can be seen to fill in the complex pattern made by the sulci of the brain.

Intra-cerebral or intra-axial bleeding

Probably the most dangerous and unpredictable type of bleeding, the hemorrhage, occurs within the brain matter and thus would be difficult to evacuate or predict the extent of damage it might cause to the related brain tissues.

The symptoms:

The intracranial bleeding can present with various symptoms and it can be an acute event or else a gradual event.

In acute episodes, the patients might present with sudden onset severe headache, paralysis or weakness, loss of consciousness, traumatic head injuries, confusion and disorientation along with restlessness…etc.

If the bleeding takes place over a time period, the patients might present with headache which is gradually progressing, nausea, blurred vision, gradually deteriorating level of consciousness, fits…etc.

Apart from the above symptoms, there might be other symptoms which can be seen in these patients.

How to diagnose an intracranial bleeding?

The diagnosis will be based on imaging studies such as CAT scans, CT scans or else MRI.

What are the treatment options?

In most instances, if the bleeding remains minimal, the body itself would be able to control the bleeding and absorb the blood that has already got accumulated. But, these patients need to be observed very carefully as if the bleeding continues and increases the pressure within the skull, a dangerous complications known as ‘herniation of the brain tissues’ can occur, which can have fatal outcomes.

Surgical evacuation of the blood or the hematoma which was formed would be practiced in many instances as this would be a sure way of preventing the build up of pressure with in the skull. The procedure would be more successful in hemorrhages taking place outside the brain rather than within.

Apart from the surgical evacuation, successful management of these patients can be achieved through the following.

1. Pressure lowering agents to maintain a low but adequate amount of pressure in the brain vasculature.

2. Osmotic diuresis through drugs such as mannitol which will reduce the pressure gradient across the blood brain barrier.

3. Correcting any underlying coagulation or clotting defects.

4. Pain relievers and anti pyretic for the fever

5. Anticonvulsant therapy to prevent fits from taking place.

Conclusion:

The process of recovery following an intra-cranial bleeding is a time consuming process and the extent to which the patient might recover would also be hard to predict. But, timely surgical intervention, adequate medical management etc would be drastically reducing the life threatening events that can occur in such conditions.


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