Brain Bleeds: Everything you should know
Bleeding in the brain, also called brain hemorrhage, is a serious medical emergency. A brain bleed can occur as a result of head trauma, brain tumors, or due to bleeding from a blood vessel. Described as intracranial bleeds, they can result in serious complications, including weakness of the body, loss of consciousness, seizures, and even death.
While brain bleeds can be diagnosed quickly with imaging tests, the key is to get medical attention as promptly as possible.
Treatment is typically aimed at reducing the bleeding, as well as managing brain edema (swelling) that occurs in response to blood. Surgical intervention may be necessary if a brain tumor or an aneurysm (abnormal blood vessel) is the cause.
Brain bleeds can affect children or adults. A brain bleed may cause symptoms that rapidly worsen over the course of hours or days.
Symptoms of a brain bleed can include:
- Head pain
- Neck or back pain
- Neck stiffness
- Vision changes
- Weakness of one side of the face and/or body
- Slurred speech
- Lethargy (extreme fatigue and sleepiness)
- Nausea and vomiting
- Behavioral changes
- Loss of consciousness
Typically, the effects of a brain bleed are severe, but they can be non-specific, so you may not recognize that they are associated with a brain issue.
Lethargy is among the most concerning issues when it comes to brain bleeds. This is because you may sleep for hours as the bleed continues to grow. A person with a growing brain bleed is at risk of not waking up from sleep or even dying.
If you or someone else has risk factors for a brain bleed or is demonstrating symptoms of a brain bleed, you need to seek medical attention urgently. Long term effects and complications may be reduced with urgent treatment.
A brain bleed may cause permanent damage to the affected regions of the brain. This could result in permanent paralysis of part of the body, cognitive disabilities (trouble thinking), recurrent seizures, and an inability to independently care for oneself.
There are several causes of brain bleeds. These events can occur suddenly due to head trauma or a ruptured blood vessel in the brain. They can develop when a stroke causes bleeding in the brain. And a tumor in the brain can lead to bleeding as well.
There are several risk factors for brain bleeds, including malignant hypertension (severe high blood pressure), recreational drug use (such as methamphetamine and cocaine), bleeding disorders, and medications that interfere with blood clotting. These risk factors can also make you more likely to experience a brain bleed after head trauma.
Elderly individuals are more susceptible to brain bleeds due to age-related changes, such as increased fragility of the blood vessels and impaired blood clotting.
Blood Vessels in the Brain
All blood vessels can bleed, but bleeding of a blood vessel is not common. There is usually a precipitating factor. Some blood vessels are more likely to bleed in response to some conditions than others.
Causes and types of bleeding in the brain include:
- Head trauma: Any type of head injury, due to a fall, a car accident, a sports injury, or an assault, can cause bleeding in the brain. The most common area of bleeding in the brain after head trauma is located between the skull and the meninges and is described as a subdural hematoma. Additionally, head trauma can also increase the risk of a stroke.
- Hemorrhagic conversion: A stroke is brain damage caused by interrupted blood flow in the brain. Most strokes occur due to ischemia, which is blocked blood flow. A large ischemic stroke can bleed after several days, causing a hemorrhagic stroke by a process described as hemorrhagic conversion. Effects can include complete paralysis of one side of the body and loss of consciousness. With treatment, recovery is often possible.
- Ruptured brain aneurysm: A brain aneurysm is an outpouching of an artery. It can burst, sometimes due to malignant hypertension, The result is a subarachnoid hemorrhage, which is a bleed underneath the meninges of the brain. A subarachnoid hemorrhage typically causes a severe headache and loss of consciousness and results in death in about 50% of cases.
- Brain tumor: A brain tumor can cause the area near the tumor to bleed. This occurs as the tumor and tumor-associated swelling produce pressure on tiny nearby blood vessels, causing then to tear and leak blood.
- Spontaneous bleeding: It is very rare for spontaneous bleeding to occur in the brain. These bleeds may affect the cerebral cortex or the internal capsule, causing the same symptoms as a stroke. A condition called amyloid angiopathy, characterized by fragile blood vessels increases the risk of spontaneous brain bleeding. Using blood thinners or having a bleeding disorder may increase the risk as well.
Brain bleeds are typically diagnosed with computerized tomography (CT) scan of the brain. These imaging tests are generally more sensitive to acute (brand new) bleeds than magnetic resonance imaging (MRI) is. MRI can usually detect brain bleeds after several hours or if they are very large.
Besides identifying the presence and location of blood in the brain, imaging tests are also able to determine the size of the bleeding. These tests can often determine whether the blood has formed a blood clot, or whether it is continuing to bleed or leak throughout the brain.
Subdural hematomas can be classified into three categories, which can be defined based on imaging tests. An acute subdural hematoma is one or two days old. A subacute subdural hematoma is between three and 14 days old. And a chronic subdural hematoma is more than two weeks old.
Severe bleeding can cause edema to develop. Sometimes, the combination of bleeding and edema can cause brain compression, which may further damage the brain. In some instances, a midline shift of the brain can be identified. This is a dangerous situation in which the brain is actually shifted to one side, which caused compression on the brain.
Follow Up Imaging
Often, with brain bleeds, follow up CT scans are needed. Follow up CT scans can determine if bleeding is continuing or has stopped. Your doctors may also be able to determine if edema is worsening, stabilizing, or improving. And follow up imaging can also determine whether the blood clot is continuing to grow, stabilizing, or shrinking.
You may need other tests may be needed to assess the cause and effect of a brain bleed, depending on the circumstances.
- Brain angiogram: In some instances, when symptoms are very consistent with a subarachnoid hemorrhage, an imaging test may not show bleeding. An angiogram may identify a brain aneurysm, even when blood is not identified on a brain CT or MRI. This can help in planning treatment.
- Lumbar puncture (LP): An LP, also called a spinal tap, can detect blood cells or cancer cells in the cerebrospinal fluid (CSF), which is the fluid that surrounds the brain and spinal cord. An LP can be dangerous if you have a large bleed, severe edema, or a risk of a midline shift because it can precipitate a midline shift. However, in certain circumstances, an LP can be helpful in assessing a brain bleed.
- Electroencephalogram (EEG): An EGG is a brain wave test that can detect seizures and predisposition to seizures. It can also help in assessing brain activity when a brain bleed has caused decreased consciousness or a coma. This is a valuable way to determine the effects of medications and edema.
There are several treatment strategies for managing a brain bleed and preventing complications. Your treatment depends on the size, location, cause, and effects of your brain bleed.
Medical and surgical intervention is usually necessary. Often, surgery is done emergently, and medical intervention may continue for weeks after surgery.
In some cases, as with a small subdural hematoma, no treatment is used at all. But close medical monitoring can help determine whether your condition worsens, in which case treatment may be needed. Often, rehabilitation is necessary after recovery from a brain bleed.
Prior to surgery, intravenous (IV) steroids are often used to reduce swelling in the brain caused by bleeding or by a tumor. Each type of brain bleed can be surgically treated, and the treatment for each type differs.
Brain bleed types and their surgical treatments include:
- Subdural hematoma: A large subdural hematoma may need to be removed surgically. Recovery can be very good, especially if there was not severe or prolonged neurological impairment prior to surgery.
- Brain tumor: A tumor and the surrounding bleeding may need to be removed. However, when there are many tumors in the brain, surgery may not be an option and radiation may be considered instead.
- Brain aneurysm: An aneurysm may need to be repaired. This is a complicated neurosurgical procedure that may be done with a minimally invasive technique in some situations.
- Edema: A hemicraniectomy involves temporary removal of a portion of the skull. This procedure does not involve the removal of blood. Instead, it relieves pressure caused by excessive edema. Once the edema subsides, the section of the skull that was removed is put back into place.
In addition to surgical interventions, medical management is often necessary. You may need to IV fluids with a closely controlled sodium concentration to prevent additional edema. Steroids are often needed to reduce edema. And anti-epilepsy drugs (AEDs) may be necessary to control seizures.
After the immediate treatment of a brain bleed, you may need physical therapy or speech therapy. Often, people recovering from a brain bleed need assistance with self-care and may need to re-learn things such as how to eat, speak, or walk.
Recovery can take a long time. It may take up to a year to regain your abilities and many people only experience partial recovery. Rehabilitation after a brain bleed is similar to the rehabilitation used after a stroke.
A bleed in the brain is often a serious neurosurgical emergency. Getting emergency treatment is the best way to optimize your outcome after a bleed in the brain. There are several types of brain bleeds, and while they are dangerous, recovery is possible. If you experience or encounter someone who is experiencing signs of a brain bleed, seek help immediately.
While rehabilitation can be exhausting, it is important not to be discouraged. After recovering from a brain bleed, you should not expect the bleeding to recur or worsen.
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