Following are some of the conditions and treatments associated with Brain Hemorrhage, Brain Aneurysm and Vascular Malformations:
Intracerebral hemorrhage (ICH)
Intracerebral hemorrhage (ICH) is a type of stroke caused by bleeding within the brain. The blood collects and forms a clot, called "hematoma", which grows and causes pressure on surrounding brain tissue. ICH is a life-threatening condition, most commonly caused by hypertension, amyloid angiopathy, and head trauma. As blood cells within the clot die, toxins are released that further damage brain cells in the area surrounding the hematoma. Acute treatment is focused preventing ongoing bleeding and removing the hematoma in selected patients to relieve the pressure effect on the brain. Ten percent of strokes are caused by ICH (approximately 70,000 new cases each year), which carries a 40% risk of death. ICH is more common in men, middle-aged African Americans, and Japanese. Approximately 70% of patients experience long-term deficits after an ICH.
What are the symptoms of ICH
Symptoms are usually sudden and vary depending on the location of the blood clot within the brain.
Symptoms of ICH include:
- Headache, nausea, and vomiting
- Lethargy or confusion
- Sudden weakness or numbness of the face, arm, or leg, usually on one side
- Loss of consciousness
- Temporary loss of vision
- Seizures
Causes of ICH
- Hypertension: an elevation of blood pressure that may cause small arteries to burst inside the brain.
- Anticoagulants (Blood thinner therapy): drugs such as coumadin, heparin, and plavix used to treat heart disease and stroke.
- Arteriovenous malformations: tangle of abnormal arteries and veins
- Ruptured aneurysm - resulting in subarachnoid hemorrhage
- Head trauma: fracture of the skull and penetrating wounds (gunshot) can damage an artery and cause bleeding.
- Bleeding disorders: hemophilia, sickle cell anemia, and low platelets
- Tumors: highly vascular tumors such as hemangiomas and metastatic tumors can bleed into the brain tissue.
- Amyloid angiopathy: a degenerative disease of the arteries in elderly patients.
- Drug usage: cocaine and other illicit drugs
- Spontaneous ICH with unknown etiology
How is ICH Diagnosed?
Computed Tomography (CT) scan is a noninvasive test to visualize the anatomical structures within the brain, and to identify if there is blood within the brain. CT angiography involves the injection of intravnous contrast through a vein and allows us to view arteries of the brain in detail. .
Magnetic resonance imaging (MRI) and MR Angiography (MRA) scans are noninvasive imaging tests which use a magnetic field and radio-frequency waves and provide our physicians with detailed views of the brain and blood vessels.
Cerebral Angiography is an invasive procedure, whereby a catheter is inserted into an artery in the groin and passed through the blood vessels to the brain. Once the catheter is in place, a contrast dye is injected into the bloodstream and X-ray images are taken to visualize blood vessels of the brain in detail.
How is ICH treated?
Patients suffering ICH require continuous close monitoring in the neuroscience intensive care unit. Generally, patients with small hemorrhages and minimal neurologic symptoms are treated medically. Patients with cerebellar hemorrhages who are deteriorating or who have brainstem compression and hydrocephalus are treated surgically to remove the hematoma as soon as possible. Patients with large lobar hemorrhages who are deteriorating may require surgical evacuation of the hematoma.
Medical treatment and control of intracranial pressure
Blood pressure is controlled with intravenous antihypertensive medication to decrease the risk of further bleeding and to provide enough blood flow (perfusion) to the brain.
Controlling intracranial pressure (ICP) is crucial in the care of patients with ICH. An ICP monitor is placed directly into the ventricles (intraventricular caheter) or within the brain to measure the pressure. Normal ICP is less than 20mm HG. Removing cerebrospinal fluid (CSF) from the ventricles is a common method to control ICP.
Surgical treatment
Surgical treatment options depend upon the location of the clot. The goal of surgery is to remove as much of the blood clot as possible and to stop the source of bleeding if it is from an identifiable arteriovenous malformation or tumor. A less invasive small surgical opening may be performed under the operating microscope with the aid of computer guidance technology.
ICH patients may suffer short-term and/or long-term disability. Some of there symptoms and disability may disappear over time with healing and physical therapy. The recovery process may take weeks, months, or years to regain function.
Aneurysm
What is an aneurysm?
An aneurysm is a balloon-like bulge in a weak area of the arterial wall. Aneurysms are located in the anterior portion of the brain (anterior circulation) in almost 80% of cases, and in the posterior portion of the brain (posterior circulation) in about 20% of cases. Aneurysms are liable to enlarge, and this can cause pressure on the surrounding brain structures according to the aneurysm's location. The aneurysm wall may become weaker as the aneurysm becomes larger and can rupture resulting in a life threatening type of stroke called subarachnoid hemorrhage (SAH), which is blood around the brain. Treatment options for ruptured aneurysms include surgical clipping, or interventional coiling.
Aneurysms can have different shapes:
- Saccular aneurysm (also called "berry aneurysm ") bulges from one side of the artery and has a well defined neck at its base.
- Fusiform aneurysm is a multidirectional enlargement of a portion of a cerebral vessel with no defined neck.
- Lobular aneurysm is more than one bulge within the same aneurysm, but it has a well defined neck at the base.
Aneurysms can have different sizes:
- small - less than 1.5 cm;
- large - 1.5 - 2.5 cm;
- giant - more than 2.5 cm
Incidence of aneurysms and risk factors for ruptured aneurysms:
Aneurysms are usually diagnosed between ages 35 to 60 and are more common in women. The Incidence of cerebral aneurysms in the general population is 5% (multiple aneurysms in 20% of patients). Unruptured aneurysms are found in 2.7 million patients per year, and ruptured aneurysms are found in 20,000 patients per year. Risk factors for aneurysm rupture are smoking, high blood pressure, alcohol intake, cocaine abuse, genetic (family inherited), atherosclerosis of cerebral arteries (hardening of the arterial wall), oral contraceptives, and stressful lifestyle.
Frequent aneurysm locations
- Internal carotid artery — 36%
- Middle cerebral artery — 33%
- Anterior cerebral artery — 15%
- Basilar artery — 6%
- Vertebral basilar — 4%
- Posterior communicating artery — 4%
- Cavernous carotid artery — 2%
What are the symptoms of a cerebral aneurysm?
Unruptured aneurysms may cause symptoms when they enlarge and start to compress surrounding brain structures such as the nerve of vision (optic nerve) or the nerve of eye movements (oculomotor nerve).
Ruptured aneurysms release blood into the spaces around the brain (subarachnoid hemorrhage). The symptoms of subacrachnoid hemorrhage (SAH) are sudden onset of severe headaches ("worst headache in your life"), nausea and vomiting, neck pain and stiffness, disturbed consciousness, and seizures.
The Hunt-Hess scale grades classify the severity of the subarachnoid hemorrhage. If the patient has a serious systemic disease such as hypertension or cardiopulmonary disease one grade level is added.
- Grade 1 - alert, mild headache, stiff neck
- Grade 2 - alert, vision problems, moderate to severe headache, stiff neck
- Grade 3 - lethargy or confusion, weakness or partial paralysis on one side of body
- Grade 4 - stupor, moderate to severe paralysis on one side of body
- Grade 5 - comatose
How are cerebral aneurysms diagnosed?
Brain aneurysm can be diagnosed using Computed Tomography Angiography (CTA) and/or Magnetic Resonance Angiography (MRA) which are noninvasive tests used to visualize arteries of the brain.
Cerebral angiogram is an invasive test used to accurately diagnose the shape and location of aneurysm and to treat the aneurysm. An arterial catheter is inserted into the femoral artery in the groin and passed through the aorta to reach the blood vessels of the brain. Contrast dye is then injected into the bloodstream and X-ray images are obtained.
Ruptured aneurysms cause subarachnoid hemorrhage and is diagnosed by Computed Tomography scan of the brain to visualize blood around the brain. Lumbar puncture (spinal tap) may also be performed to detect blood in the cerebrospinal fluid. These tests are often followed by a CT angiogram and/or a cerebral angiogram.
How are aneuryms treated ?
Treatment of unruptured aneurysms depend upon the following factors: 1. size and location of the aneurysm, 2. patient age, and 3. patients overall state of health. Options include observation and serial imaging to observe for aneurysm growth using CTA or MRA, surgical clipping, or coiling. The treating neurosurgeon and interventional neuroradiologist work together, discuss treatment options, and make recommendations for your individual case.
Ruptured aneurysms may re-bleed in approximately 20% of cases during the first two weeks after a SAH. Definitive treatment is, therefore, required for ruptured aneurysms. Ruptured aneurysms are treated by surgical clipping or endovascular coiling. The best treatment option of surgical clipping versus endovascular coiling depends upon the size and location of the aneurysm, patient age, and patient health/clinical condition.
Surgical clipping of cerebral aneurysms
The most common treatment for cerebral aneurysms is direct surgical clipping. The operation is performed under general anesthesia. An opening is made in the skull (craniotomy). The brain is gently retracted (moved slightly) so that the artery with the aneurysm can be located. A permanent titanium clip is placed across the "neck" of the aneurysm to block the blood flow from entering into the aneurysm. Depending upon the sized and location of the aneurysm, the surgeon may partially clip the aneurysm and wrap the remaining portion with surgical cotton fibers, or completely block the artery involveds the aneurysm. In this case an arterial bypass may be required to restore blood flow around the occluded section of the artery by inserting a bypass graft.
Minimally evasive surgical clipping of cerebral aneurysms
IIn some cases, more minimally evasve techniques can be used such as an eyelid skin iincision or minipeterional craniotomy.
Endovascular coiling
In contrast to surgery, endovascular coiling may be required to treat an aneurysm. Coiling is performed in the angiography suite of the Radiology Department by Interventional Neuroradiology. The procedure usually requires general anesthesia. During the procedure an arterial catheter is inserted into the femoral artery in the groin and passed through the aorta to reach the blood vessels of the brain and the aneurysm. The interventional neuroradiologist guides the catheter through the bloodstream while watching an x-ray monitor. Small platinum coils are introduced into the aneurysm under direct visualization. The coils cause blood to clot within the aneurysm and will prevent blood flow into the aneurysm. After a coiling procedure a follow-up angiogram is performed periodically to confirm the aneurysm is still occluded and not recurring (re-canalize).
Subarachnoid hemorrhage (SAH)
Subarachnoid hemorrhage (SAH) is a type of stroke caused by bleeding into the subarachnoid space in the area between the brain and the skull which normally contains cerebrospinal fluid (CSF). SAH can be caused by a ruptured aneurysm, head trauma, or bleeding arteriovenous malformation (AVM). SAH occurs in 1 out of 10,000 people each year. Women have a slightly higher risk of SAH than men with an average age of 50 years. SAH is caused by a ruptured aneurysm in 77% of cases and 5-10% of all strokes are due to SAH.
One third of the patients who suffer a SAH will survive with good recovery; one third will survive with a disability; and one third will die. Treatment of patients with subarachnoid hemorrhage focuses on controlling the source of bleeding (i.e. aneurysm or arteriovenous malformation), restoring normal blood flow to the brain, and relieving the pressure within the brain.
Treatment of SAH should begin as soon as possible because there is a 20% chance of recurrent hemorrhage within 14 days. Once the cause of the bleeding (aneurysm, AVM) is identified, surgery or coiling is performed to prevent recurrent bleeding. A common complication of aneurysmal SAH is vasospasm, which is a narrowing (spasm) of an artery in proximity to the bleeding aneurysm. Vasospasm can occur 3-14 days following a SAH. Vasospasm narrows the artery and reduces blood flow to regions of the brain. Vasospasm can cause additional disability by reduction of blood flow resulting in new areas of stroke.
SAH patients are closely monitored in the neuroscience ICU every hour for signs of vasospasm which include weakness in an arm or leg, confusion, sleepiness, or restlessness. If vasospasm is suspected, transcranial doppler (TCD) ultrasound is used to measure the flow of blood through the arteries, we perform CT/MR scans to measure blood flow, and cerebral angiography may be required. Treatment of vasospasm includes intravenous fluids, vasodilator drug treatment (Nimodipine for 14-21 days), and medications to elevate blood pressure. This treatment is called Triple H therapy (Hypertension, Hypervolemia, Hemodilution). SAH patients may require an angiogram during which a dilator medicine can be injected into spastic arteries and/or balloon dilatation (angioplasty) may be used to stretch open the artery.
Survival rates in patients with SAH dependupon the Hunt-Hess scale grade of severity
- Grade 1 - 75% survival
- Grade 2 - 60% survival
- Grade 3 - 50% survival
- Grade 4 - 30% survival
- Grade 5 - 10% survival
Vascular Malformations
Vasular malformations of the brain and the spinal cord classified as follows:
- Arteriovenous malformations: abnormal collection of blood vessels without normal brain tissue in-between.
- Cavernous malformation (also known as cavernoma, cavernous angioma, cavernous hemangioma): a collection of dilated irregular venous spaces without normal brain tissue in-between.
- Dural arteriovenous fistula: connection between arteries and veins within the dura matter layers (covering of the brain) creating abnormal shunts.
- Venous angiomas: a tuft of functionally draining veins which can be superficial or deep and most often do not require treatment.
Arteriovenous malformations (AVM)
AVM is a congenital lesion that tends to enlarge with age. AVM appear as tangles of abnormal arteries and veins with a central core (nidus) which has no normal brain tissue in between. The incidence of AVM in the population is 0.14% with a slight male predominance. The average age at diagnosis is 33 years.
What are symptoms of AVM ?
- Brain Hemorrhage occurs in 50-60% of patients. The annual risk of hemorrhage and recurrent hemorrhage from AVM is 2-4%. For a middle age patient, the life time risk of bleeding can be as high as 60%. Brain hemorrhage from ruptured AVM can result in death in 10% and severe disability in 30-50% of patients.
- Seizures
- High Intracranial Pressure - pressure effect on the brain structures according to location
- Stroke - symptoms due to decreased blood flow involving normal areas of the brain close to the AVM (steal phenomenon)
How is AVM diagnosed?
Comuted Tomography (CT) scan is a noninvasive test used to visualize the normal anatomical structures within the brain and areas of brain hemorrhage. CT angiography involves the injection of contrast into the blood stream allows visualization of the arteries of the brain.
Magnetic resonance imaging (MRI) and MR Angiography (MRA) is a noninvasive test, which uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues and examines the blood vessels of the brain. MRI scan is used to visualize the exact location and size of the nidus of the AVM.
Digital subtraction angiography is required to study AVM and determine the main arterial supply of the AVM as well as the venous drainage. These are important aspects of the AVM that are used to determine optimal treatment.
Grading of AVMs
Based on diagnostic studies, AVMs are graded according to the size of the nidus, location in the brain (functionally critical areas or not), and venous drainage (superficial or deep. AVMs are associated with aneurysms in 7% of cases and the location of the aneurysms can be within or away from the nidus of the aneurysm.
How are AVM's managed?
Treatment of AVM depends upon the size, location within the brain (eloquent area are critically functional or non-eloquent), venous drainage (superficial is less critical and deep is more critical), patient's age and health condition. AVM's are evaluated by the treating team who determine and recommend a management course for the patient.
Surgical Resection
Surgical resection is a definitive curative treatment for AVM and is often performed after angiographic embolization of the AVM. Surgery is performed under the operating microscope with the aid of intra-operative computer guidance. Large AVM's in eloquent areas of the brain with deep venous drainage are usually not treated surgically.
Endovascular Embolization
Embolization facilitates surgical resection of AVMs. Embolization is usually done in multiple sessions to avoid sudden changes of the hemodynamics of the cerebral circulation in the AVM region. Embolization may provide permanent occlusion of some AVMs.
Stereotactic Radiation Therapy
Stereotactic Radiosurgery (SRS) can be done for AVMs less than 3cm in size. Fractionated stereotactic radiation therapy can be used to treat larger AVMs. Radiation treatment can be performed in conjunction with interventional embolization. Radiation treatmenteffects may evolve over 1-3 years during which there is still a risk of bleeding.
Cavernous Malformations (cavernomas, cavernous hemangiomas)
Cavernomas are congenital lesions comprise 5-13% of vascular malformations and affects 0.02-0.13% of the population. Mulitple cavernomas are found in 50% of patients. Cavernomas may be genetically inherited and run in families (mainly Hispanic) in a small percentage of patients. Cavernomas are no flow malformations formed from a collection of abnormal veins (sinusoids) resembling a mulberry, and may be accompanied by calcium deposition.
What are the symptoms of Cavernoma?
- 50% of cases are incidentally found with no prior symptoms
- Seizures are the presenting symptom in 60% of cases.
- Intracerebral hemorrhage is the presenting sign in 20% of cases. The risk of brain hemorrhage is 2.5-3% per year.
How are cavernomas diagnosed?
Computed Tomography (CT) scan is a noninvasive test to visualize the anatomical structures within the brain, and to identify if there is any blood or calcification within the brain tissue.
Magnetic resonance imaging (MRI) scan is the most sensitive test for the diagnosis of cavernomas.
How are cavernomas managed?
Observation and radiological follow-up is often recommended for patients with asymptomatic incidentally discovered cavernomas. Small cavernomas presenting with small non significant hemorrhage may also be observed with close regular follow up.
Surgical Resection is a curative treatment for Cavernomas. Surgery is performed under the operating microscope with the aid of intra-operative computer guidance. Surgery is indicated in cavernomas causing focal neurological deficit, repeated hemorrhage, and seizures.
Stereotactic Radiation Therapy (SRS) is a controversial treatment modality for the treatment of cavernomas and may be considered under specific circumstances.
Dural Arteriovenous Malformations (Dural AVM)
Dural AVM is a vascular malformation contained within the leaflets of the dura matter.Dural AVM comprises 10-15% of all AVMs, the majority of patients (66%) are female.
What are the symptoms of Dural AVM ?
The presenting symptoms depend upon the location of the dural AVM. The back part of the brain is the area most commonly affected. Symptoms included pulsatile tinnitus (wringing in the ears), headache, visual disturbances, or brain hemorrhage.
How is Dural AVM diagnosed?
Computed Tomography (CT) scan is a noninvasive test to visualize the anatomical structures within the brain, and to identify if there is any blood within the brain tissue.
Magnetic resonance imaging (MRI) and MRA scans
Digital Subtraction Angiography is the most sensitive test to diagnose Dural AVM.
How are Dural AVMs Managed?
Observation and radiological follow-up is often recommended for patients with incidentally discovered dural AVM.
Endovascular embolization can be a definitive treatment in some cases of Dural AVM. Some patients may require endovascular embolization followed by surgery.
Surgical Resection is a curative treatment for Dural AVM. Surgery is performed under the operating microscope with the aid of intra-operative computer guidance. Surgery is indicated in Dural AVM causing focal neurological deficit, repeated hemorrhage, or persistent symptoms.
Stereotactic Radiation Therapy (SRS) can be performed post-embolization, or can be reserved for Dural AVMs that fail other treatments. The rate of complete obliteration is 50-60%.
