Brain Haemorrhage and Stroke: Emergency Neurosurgery

Thrombolytic therapy (tPA) and mechanical thrombectomy are at the forefront of treatment. The role of neurosurgery: decompressive craniectomy in large infarcts.

Haemorrhagic Stroke (15%): Bleeding as a result of a ruptured brain blood vessel. It is divided into two main types: intracerebral haemorrhage and subarachnoid haemorrhage. Neurosurgery is at the centre of treatment.

Intracerebral Haemorrhage (ICH)

Causes

The most common cause of intracerebral haemorrhage is the damage caused by long-term high blood pressure to the small vessels of the brain; amyloid angiopathy in advanced age is also a frequent cause.¹ The use of blood thinners increases the risk.² Less commonly, vascular anomalies such as arteriovenous malformations (AVM), cavernomas, and bleeding into a tumour can also be the cause.³

Cerebellar haemorrhages larger than 3 cm are an indication for surgical intervention.

Localisation

Putaminal haemorrhage (most common), thalamic haemorrhage, cerebellar haemorrhage, lobar haemorrhage, pontine haemorrhage.

Surgical Indications

Cerebellar haemorrhages larger than 3 cm are an indication for surgical intervention.⁴ Surgery is generally not indicated for deep-seated (thalamic, pontine) haemorrhages.

Subarachnoid Haemorrhage (SAH)

Cause

85 percent cerebral aneurysm rupture.^5,6 Presentation with the "worst headache of my life" (thunderclap headache) is typical. It is accompanied by neck stiffness, nausea, vomiting, and confusion.

Emergency Management

Diagnosis with CT (93-100% sensitivity in the first 24 hours), aneurysm localisation with CT angiography.^7,8

Treatment Options

Endovascular Coiling: Platinum coils are placed into the aneurysm via a catheter from the groin. Today, it is the first choice for many aneurysms.^9,10

Surgical Clipping: A clip is placed on the neck of the aneurysm via craniotomy. It is preferred for wide-necked or branch-related aneurysms.

Complications

Vasospasm (days 3-14), hydrocephalus, rebleeding, electrolyte imbalance. Intensive care monitoring is mandatory.

Decompressive Craniectomy

When brain swelling poses a life-threatening risk in large ischaemic infarcts or large haematomas, a portion of the skull bone is removed to make room for the brain. The bone is later replaced (stored at -80°C) (cranioplasty).

→ Next page: S53 — Common Misconceptions