Definition

An intracerebral haemorrhage is a bleeding within the brain tissue. In most cases, the accompanying condition of increased blood pressure is considered to be the cause. The haemorrhage is then often localised in the area of the so-called "basal ganglia" (motor centres of the brain). Other causes of intracerebral haemorrhages can be anticoagulant medication with phenprocoumon (e.g. Marcumar®) or acetylsalicylic acid, an arterio-venous malformation or an aneurysm.
Intracerebral haemorrhages lead to a blood clot, which has a space-occupying effect on the brain in a closed system and often results in an increase in the so-called intracranial pressure (pressure inside the skull).

Symptoms

Intracerebral haemorrhage is sometimes characterised by a sudden headache followed by a loss of consciousness (drowsiness). In other cases, there is an increasing headache, which is accompanied by a clouding of consciousness. In the case of haemorrhage caused by a blood pressure derailment, hemiplegia and possibly also speech impairment often occur. Haemorrhages that are localised in the cerebellum are often accompanied by symptoms of dizziness, speech disorders, coordination disorders and gait disorders.
If such symptoms occur, it is vital that the patient is hospitalised as quickly as possible. A computer tomogram of the head is carried out for emergency diagnosis. If it is a so-called atypical haemorrhage (not only in the brain or at an atypical location), which suggests an aneurysm or a pathological vascular irregularity as the cause, further diagnostic procedures, for example with a catheter vascular examination, are necessary.

Therapy

The further treatment of an intracerebral haemorrhage must be decided depending on the localisation and extent of the haemorrhage and the clinical condition of the patient. One possible surgical treatment is the insertion of a drain into a cerebral ventricle for acute pressure relief, or microsurgical surgical evacuation of the haemorrhage. All patients with an intracerebral haemorrhage are always monitored in our intensive care unit. The aim is to quickly wean the patient off the ventilator in order to allow a clinical assessment of alertness and neurological deficits.

Prognosis

The 30-day survival essentially depends on the size, localisation of the haemorrhage, age and secondary diseases. Overall, deeper haemorrhages have a lower chance of survival than superficial, smaller haemorrhages. It should be noted that such haemorrhages often result in permanent impairments that cannot be reversed.

Definition

Aneurysms are a spindle- or sac-shaped permanent dilation of the cross-section of blood vessels as a result of congenital or acquired changes to the vessel wall. This vascular protrusion can be as small as a few millimetres or as large as a few centimetres. A haemorrhage caused by an aneurysm in the head (subarachnoid haemorrhage) accounts for around 10% of all strokes. Often a subarachnoid haemorrhage is not preceded by any special features. In many cases, the haemorrhage occurs in conjunction with increased pressure or heavy physical exertion.

Incidence

The exact frequency with which aneurysms occur in Germany is unknown. However, aneurysms rupture (burst) in 6 - 12 cases per 100,000 inhabitants per year. Overall, women are affected slightly more frequently than men (3:2). The peak age is between 45 and 65 years. Risk factors include high blood pressure, nicotine consumption and a close relationship to someone who has already had a haemorrhage due to a ruptured aneurysm in the head (spontaneous subarachnoid haemorrhage).

Anatomy and distribution of aneurysms

An aneurysm consists of a neck and an aneurysm sac. The aneurysm rupture usually occurs at the thinnest part of the vessel sac.
The saccular aneurysms occur preferentially at the base of the brain. This is where the 4 main arteries responsible for the blood supply to the brain unite to form a circle (Circulus arteriosus Willisii).
Distribution of aneurysms at the various cerebral arteries:

• Arteria cerebri media (20 -25%)
• Anterior communicating artery (35 - 40%)
• Internal carotid artery (30%)
• Posterior circulation (10%)

Therapy

As the risk of re-bleeding from an aneurysm that has already haemorrhaged is significantly increased, particularly within the first few days after the haemorrhage has occurred, the aneurysm should be quickly removed from the bloodstream (within 48 hours of the haemorrhage).
Emergency diagnostics after a subarachnoid haemorrhage initially includes a computer tomography of the head with vascular imaging (CT angiography). In most cases, catheter angiography is performed in addition to more precise visualisation of the aneurysm and, if necessary, simultaneous treatment.
There are two basic methods of aneurysm treatment:

1. On the one hand, there is the option of endovascular (catheter-based) aneurysm treatment using so-called "coiling". In this procedure, platinum coils are inserted into the vascular sac during angiography. The aneurysm thus "plugs" itself from the inside and is thus excluded from normal blood circulation.
2. The second treatment option is to remove the aneurysm using a clip during an operation. Various examinations are carried out during the operation, which can show that the aneurysm has been completely eliminated. In this respect, the Zeego® hybrid operating theatre, which is unique to our clinic, is an ideal way of checking the success of the operation directly during surgery.

The decision as to whether surgical or endovascular treatment is an option depends mainly on the structure and localisation of the aneurysm.
Postoperatively, every patient is monitored and treated in the intensive care unit. The duration of intensive care treatment differs mainly depending on whether the patient has been treated for an accidentally discovered (incidental) aneurysm or whether the patient has suffered a haemorrhage from the aneurysm. These patients with a subarachnoid haemorrhage require prolonged (10 - 14 days) intensive medical monitoring, as the risk of complications following a haemorrhage persists in the initial period even after the aneurysm has been removed.
In this regard, particular reference should be made to the so-called "vasospasm". Vasospasm is a cramp-like constriction of the vessels supplying the brain, which can lead to reduced blood flow and thus reduced supply to the brain. To detect a vasospasm, patients are continuously monitored in the intensive care unit and ultrasound examinations are carried out daily.

A major advantage of these operations is the immediate, complete and permanent elimination of the risk of bleeding. The Zeego® hybrid operating theatre, the only one of its kind in our clinic, allows us to perform intraoperative catheter angiography so that the complete removal of the AVM can be documented during the operation. In the event of a residual vascular malformation, this can be removed during the same operation.
Small AVMs that are located deep in the brain and are therefore not accessible for surgical treatment can also be treated with targeted, one-off radiotherapy.
An interdisciplinary case discussion is therefore crucial for optimising individual treatment.

Definition

Dural arterio-venous fistulas are acquired short-circuit connections of arteries and veins on the hard meninges. The mechanism of development is not yet fully understood, but is thought to be the result of a drainage problem in the area of the brain (sinus thrombosis).

Symptoms

Symptoms of dural arterio-venous fistulas are headaches and a pulse-synchronised ringing in the ears.

Therapy

Here too, the treatment options differ between endovascular, catheter-based (closing from the inside) and surgical procedures.

Definition

Arterio-venous malformations (AVM) are vascular malformations of the brain that represent a short circuit between arteries and veins. Due to the increasing availability of imaging techniques, asymptomatic AVMs, i.e. AVMs that do not cause symptoms, are being diagnosed more and more frequently. A frequency of 0.01 - 4% is assumed in the population. The risk of haemorrhage is determined in particular by the structure of the vascular malformation, its size and its location. It varies between 1-30% / year. The individual risk of haemorrhage depends on various factors. Symptoms:About 40-60% of patients with AVM become conspicuous by a haemorrhage. In these cases, headaches, seizures, neurological symptoms such as paralysis (loss of strength) and even a loss of consciousness occur.Diagnosis:As with other haemorrhages, the emergency diagnosis for this clinical picture also consists of a computer tomography of the head with simultaneous vascular imaging (CT angiography). However, in the case of a newly diagnosed AVM, catheter angiography is essential for more precise visualisation of the feeding and draining vessels. In the case of a haemorrhage that has taken place, the resorption of the haemorrhage must first be awaited, as the examination cannot be adequately assessed in the case of a fresh haemorrhage, so that this examination should only take place during the course of the disease. Therapy:With regard to the therapy of AVM, the normal risk of bleeding must be compared with the risk of treatment. As there is a risk of bleeding that accumulates over the years, young patients in particular should be treated. The aim of treatment is always to completely eliminate the vascular malformation from the normal blood circulation. There are basically two different treatment methods. 1. an "adhesion" of the vascular malformation during catheterisation, or 2. surgical exposure and microneurosurgical removal of the AVM.