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How can my father's brain haemmorhage be managed?

Q: My father has got brain-haemorrhage. He is 58 years old. The CT scan report says: A large acute haematoma measuring 3.1 x 1.7 cm is seen in the pons, which is swollen. It extends into the left cerebellar penduncle and the left cerebellar hemisphere as well as into the adjacent cisterns and the 4th ventricle. The 3rd ventricle is rounded. The lateral ventricles are normal. Supra & infratentorial parenchyma is normal. Sulcal spaces are normal. What is your opinion?

A:The term used for conditions in which an area of the brain is transiently or permanently affected by ischemia (lack of blood supply) or bleeding is cerebrovascular disease (CVD). One or more of the blood vessels in the brain may be involved in the pathological process. Intracranial haemorrhage is the pathological accumulation of blood within the cranial cavity and this may occur within the brain parenchyma (intracerebral haemorrhage) or the surrounding meningeal spaces. Haemorrhage within the meninges or the associated potential spaces is called epidural haematoma, subdural haematoma, and subarachnoid haemorrhage. Intracerebral haemorrhage (ICH) may extend into the ventricles and is then called intraventricular haemorrhage. ICH results from a wide variety of disorders and is more likely to result in death or major disability than other forms of bleed as the haemorrhage itself and the accompanying swelling may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. If large parts of the brain are so displaced, there is rise in the intracranial pressure (ICP) which can cause potentially fatal brain stem herniation. Common causes for this include trauma; ruptured intracranial aneurysms (congenital weakening of blood vessels); arteriovenous malformation (an abnormal collection of blood vessels where arterial blood flows directly into draining veins); vasculitis; tumour; use of anticoagulants; bleeding disorders like haemophilia. The cause may be unknown in nearly 25% cases. A haemorrhage in the brainstem region may present with coma, posturing, loss of brainstem reflexes,and oculomotor abnormalities. It most commonly involves the pons and generally has a poor prognosis. The immediate management is largely dependent upon the cause, location, and size of the haemorrhage, as well as the clinical status of the patient. CT angiography or MR angiography permits visualisation of the blood vessels for arterial diseases like arterio-venous malformations, vasculitis, etc. Medical treatment is given when there is minimal neurological deficits or the bleed is less than 10 cc. Some of the indications for surgery are - haemorrhage more than 3 cm, presence of a structural vascular lesion, lobar haemorrhage, etc. Surgery may include craniotomy and clot evacuation under direct vision; stereotactic aspiration with thrombolytic agents or endoscopic evacuation. The treating neurosurgeon would be best placed to evaluate and advise.


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