Brain hemorrhage is a catastrophic condition. Majority of these patients present with sudden headache and unconsciousness. This condition requires early diagnosis and prompt management.
Common causes of brain hemorrhage include:
1. Uncontrolled blood pressure (hypertension) -- basal ganglia, thalamic, pontine bleeds, lobar hematoma.
2. Vascular anomalies as aneurysm, arteriovenous malformations.
3. Coagulopathy induced bleeds -- This is seen in patients with blood thinning drugs like aspirin, clopidrogel, acitrom, warfarin, heparin.
4. Less common causes include tumor with bleed, cortical vein thrombosis.
Surgical treatment is required for two reasons:
1. Those with large hematoma cause increased pressure in brain and affect the functioning of the normal brain. CT scan provides information about the size of the hematoma and the extent of pressure. Immediate surgery is required to evacuate the hematoma. In those with underlying cause as aneurysm, AVM, tumor, appropriate surgical intervention for thios can also be done simultaneously.
2. To avoid re-bleed-- Vascular lesions have a high incidence of rebleed if they are not intervened in timely manner. Aneurysms require to be clipped as early as possible. Few of the cases have been clipped within 6 hours of bleeding. The aim is to secure the aneurysms as early as possible so as to avoid catastrophic re-bleeds and reduce the incidence of vasospasm.
Dr Nitin Garg performs clipping of intracranial aneurysms (one of largest series in Central India). He has experience of performing intra-operative ICG angiography
which is a paradigm shift in vascular neurosurgery. The microscope available at Bansal hospital has inbuilt capability of performing ICG angiography. All types of aneurysms as Anterior communicating artery, middle cerebral artery, distal anterior cerebral artery, internal cerebral artery, posterior communicating artery aneurysms can be managed using surgical methods. Even posterior circulation aneurysms like basilar artery, vertebral artery, PICA aneurysm have been clipped in those who are not able to afford endovascular options. Intra-operatively, adjuncts like neuro-protection, temporary adenosine arrest prolong temporary clip timing to allow for permanent clip to be applied appropriately.
With increasing use of anti-platelet agents and anti-coagulants, coagulopathy induced bleeds have become more frequent. A prompt correction of the disordered coagulation is the basis of treating these patient. This helps to avoid the increase in the size of the bleed and also aids in surgical evacuation if required. An effecient and in-house blood bank is very helpful to provide immediate blood products as platelets, FFP.
Arteriovenous malformations are excised depending upon the location and the size.
Spinal dural Arterior-venous fistulas are also managed surgically. Dr Nitin Garg has experience of surgical occlusion of these fistulas.
The standard protocol is to perform a CT Angiography for delineation of the anatomical characteristics of the anomaly. DSA is seldom required. It is performed in those with angionegative SAH, AVMs to assess the dynamic flow, and in spinal lesions. Post-operatively, the patient is closely monitored for vasospasm in ICU setting. Patients who develop vasospasm, triple-H therapy is constituted with intensive monitoring of blood pressure, fluid status.