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Monday, 2 December 2013

Upper head hemorrhaging: Cerebral hemorrhage - The Diagnosis and Treatments

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Cerebral hemorrhage
Cerebral hemorrhage, a sub type of intracranial hemorrhage, is defined as a condition of  bleeding as a result of artery bursts in the brain, considered as one of the main cause of stroke, according to the research article of Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus(1).
Diagnosis
1. Computed tomography (CT) scan
If your doctor suspects the bleeding is within the brain itself, then CT scan is the best choice. Computed tomography (CT) is the standard diagnostic tool uses X-rays to make detailed pictures of structures inside the skull to check for fractures and bleeding, specially in case of trauma. Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores, according to the study by The University of Texas-Southwestern Medical Center(12).

2. A Lumbar puncture
If CT scan can not identify the diagnosis, your doctor may suggest a lumbar puncture (spinal tap) to rule out subarachnoid hemorrhage. Lumbar puncture or a spinal tap may be necessary to collect a sample of cerebrospinal fluid (CSF) to check for the presence of blood. There is a report of two cases of spinal epidural hematoma and two cases of intracranial subdural hematoma after lumbar puncture (LP) are reported in children receiving chemotherapy for acute lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was asymptomatic but interfered with treatment in one case, and caused either severe backache or headache but no neurological deficit in the other three patients(13).

3. Other tests such as
a Magnetic resonance imaging (MRI) can be helpful  in detecting structural abnormalities of the body to determine the extent of injury to the brain. 

b. Arteriography
In case a ruptured aneurysm is suspected, arteriography, a medical imaging technique used to visualize the inside, or lumen, of blood vessels to pinpoint the location of the ruptured aneurysm. 

4. Etc.

D.2.4. Treatments 
Depending on the underlying abnormality 
1. Medication
a. Antihypertensive therapy
In the study of the efficacy of the American Heart Association/American Stroke Association guidelines for ultra-early, intentional antihypertensive therapy in intracerebral hemorrhage, showed that there are clinical benefits, by the prevention of subsequent HE, in maintaining a MAP level lower than that recommended by the the American Heart Association/American Stroke Association (AHA/ASA) (110 mm Hg) after hospitalization for patients who have intracerebral hemorrhage (ICH)(14).

b. Factor VII
Factor VII is a protein that causes blood to clot. Several studies have demonstrated successful correction of the international normalized ratio (INR) using prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa). To our knowledge, no study has directly compared these agents for treatment of warfarin-related ICH(15).

c. Mannitol and hypertonic saline
In the study to develop effective strategies for the medical treatment of ICP in cases of ICH, we evaluated the therapeutic efficacy of mannitol and hypertonic saline in a canine model of ICH, found that
hypertonic saline, in both 3 and 23.4% concentrations, is as effective as mannitol in the treatment of intracranial hypertension observed in association with ICH. Hypertonic saline may have a longer duration of action, particularly when used in 3% solution. None of three treatment regimens influence regional cerebral blood flow or cerebral metabolism(16).

d. Acetaminophen to relieve the symptoms of  headache and  body temperature.

e. Corticosteroids
Corticosteroids, a synthetic drug and closely resemble cortisol, which is produced by the adrenal glands may be used in case of hypertensives and swelling.

f. Etc.

2. Non medical treatments
a. In case of intracranial pressure, placement of intracranial pressure monitors (The intracranial pressure (ICP) is monitored and ICP also can be lowered by draining cerebral spinal fluid (CSF) out through the catheter) by non-neurosurgeons: Excellent outcomes can be achieved. Placement of ICP monitors may be performed safely by both neurosurgeons and non-neurosurgeons. This procedure should thus be considered a core skill for trauma surgeons and surgical residents alike, thereby allowing initiation of prompt medical treatment in both rural areas and trauma centers with inadequate neurosurgeon or fellow coverage, according to the study by Department of Trauma Services, Via Christi Hospital on Saint Francis (J.M.H.(17).

3. Surgery
a. Non invasive treatment
Interventional radiology involves treatments that include passing a catheter to widen or to close off blood vessels in the brain without surgery(18).

b. Surgery
"Currently, most neurosurgeons in the UK would operate on patients with a deteriorating conscious level and a worsening neurological deficit. In addition, haematomas between 20—80 ml in volume are more likely to be operated upon as are lobar/superficial haematomas. With cerebellar haemorrhage, although there are again no randomized controlled trials comparing surgical and conservative treatment, there seems to be greater agreement that hematomas greater than 3—4 cm should be operated upon, especially when there is concomitant clinical deterioration or hydrocephalus", according to the study of Surgical treatment of intracerebral haemorrhage by University of Newcastle upon Tyne, Newcastle upon Tyne, UK (19).
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Sources
(1) http://www.biomedcentral.com/1471-2377/7/1
(12) http://www.ncbi.nlm.nih.gov/pubmed/22929497 
(13) http://www.ncbi.nlm.nih.gov/pubmed/16155928
(14) http://www.ncbi.nlm.nih.gov/pubmed/20541417?dopt=Abstract
(15) http://www.ncbi.nlm.nih.gov/pubmed/21492631
(16) http://www.ncbi.nlm.nih.gov/pubmed/10232539
(17) http://www.ncbi.nlm.nih.gov/pubmed/22929484
(18) http://www.cedars-sinai.edu/Patients/Programs-and-Services/Stroke-Program/Stroke-Resources/Cerebral-Hemorrhage.aspx
(19) http://bmb.oxfordjournals.org/content/56/2/444.full.pdf