Brain hematoma

Hematoma of the brain is a limited area of ​​blood accumulation in the cranial cavity. In relation to the brain and its membranes, several species are distinguished by hematomas. Each species has its own clinical signs. The formation of hematomas occurs as a result of ruptures of blood vessels passing inside the skull. Brain hematoma is a very dangerous condition requiring immediate medical intervention. Treatment can be conservative and operative. From this article you can learn about the types of hematomas and the ways of their treatment.

Causes

Hematoma of the brain is a hemorrhage, which has relatively clear boundaries. Hemorrhage occurs as a result of rupture of the vessel, the causes of which can be:

• trauma of the skull with damage to blood vessels;
• abnormalities of the structure of blood vessels (aneurysms, arteriovenous malformations);
instagram viewer
• hypertonic disease;
• a violation of blood clotting (eg, hemophilia or leukemia, anticoagulants);
• Vascular diseases of allergic and infectious-allergic nature (rheumatism, systemic lupus erythematosus, nodular periarteritis and others);
• malignant neoplasms.

The most common causes of hematomas are trauma, hypertension and cerebral vascular anomalies. Especially often, craniocerebral trauma is accompanied by the appearance of a hematoma in people who abuse alcohol.

Symptoms of brain hematoma

Symptoms of hematomas of the brain depend on their variety. In the place of origin, the following species are distinguished by hematomas:

• epidural: located between the outer shell of the brain (solid) and bones of the skull;
• subdural: located under the dura mater (between the solid and arachnoid shells);
• intracerebral: localized directly in the thickness of the brain tissue.

By the time of occurrence of hematomas are:

• acute: they form and make themselves felt about the first 3 days after the onset of hematoma formation (before capsule formation);
• subacute: clinical symptomatology appears during the formation of the hematoma capsule. This is an interval from 4 days to 15 days;
• chronic: signs of a hematoma appear after 15 days or more of the effect of the causative factor.

The size of the hematoma (epi- and subdural) are:

• small: the volume of blood poured up to 50 ml;
• medium: from 51 ml to 100 ml;
• large: over 100 ml.

Hematomas of the brain can be single and multiple, one- and two-sided, and the combinations can be very diverse. For example, left-sided small epidural hematoma and right-sided middle subdural hematoma in the same patient as a result of a traumatic brain injury.

If the hematoma is formed as a result of a craniocerebral injury, then it can be located not only in the zone of impact, but also from the opposite side - the zone of the shock.

Epi- and subdural hematomas have a direct compression of the brain, which determines the symptoms. Intracerebral hematomas cause impregnation of the brain tissue with blood, the affected areas lose their functions, which is also manifested by clinical signs.

Epidural hematoma

This type of hematomas is formed at the site of the traumatic factor: a blow to the head by some object, falling on a hard surface. Most often localized in the temporal and parietal areas (60-70%), much less often in the occipital and frontal.

Since the epidural hematoma is formed between the dura mater and the bones of the skull, The area of ​​its distribution is limited to the bone seams, to which a solid cerebral shell. It is sagittal, coronal, lambdoid-shaped sutures. Because of these anatomical features, the epidural hematoma has the shape of a biconvex lens with a maximum thickness in the middle. "Flowing" of blood beyond the places of attachment of the dura to bones from one area to another is simply impossible, then there is, arising in the temporal region on the one hand, epidural hematoma can not spread to another temporal region. For the same reason, epidural hematomas are not formed on the basis of the brain, since there the dura mater is tightly fused to the bones of the skull.

Symptoms of epidural hematoma depend on the volume and rate of development of hemorrhage. In case of arterial injuries, the epidural hematoma forms quickly, usually of large size, which causes the development of violent symptoms. If venous vessels are damaged, the rate of bleeding is small, the hematoma is formed more slowly, so the clinical picture is not so bright and develops gradually.

Epidural hematomas are predominantly acute. Subacute and chronic are very rare, mainly in elderly people with age-related atrophic changes in the brain.

The most characteristic for all epidural hematomas are the following symptoms:

• light interval: the time from the effects of the trauma agent to the onset of symptoms. Usually, trauma is accompanied by loss of consciousness, which is then completely restored, can be disturbed by a mild headache, mild dizziness, nausea and weakness. And then a progressive deterioration of the condition begins, that is, the light interval ends;
• on the side of the hematoma the pupil dilates and the eyelids drop;
• on the opposite side of the body there are signs of pyramidal insufficiency (rising tendon reflexes, pathological symptoms appear as Babinsky, possibly development muscle weakness).

Symptoms arise from the compression of the brain tissue with blood. The pressure appears on directly adjacent structures, and other parts of the brain undergo displacement. There is a hypertensive-dislocation syndrome, that is, intracranial pressure increases with simultaneous displacement of some parts of the brain. This is manifested by the onset of psychomotor agitation, which is replaced by depression of consciousness and gradual development of coma. While the patient is conscious, he is disturbed by the severe headache, there can be indomitable vomiting. Gradually, as a result of the displacement of brain structures, blood pressure rises, breathing becomes more rapid, cardiac reduction (bradycardia), on the side of the lesion the pupil is widened, on the opposite side - the pyramidal failure. Increasing compression of the brainstem can lead to the emergence of severe violations of breathing and blood circulation, as a result of which the patient may die.

The time from the onset of the first symptoms of a hematoma to a coma with violation of breathing and palpitation can be very different: from several hours to several days. It depends on the volume of blood flowing and the location of the localization.

Subdural hematoma

This variety is the most common among all clinical forms of hematomas. Unlike epidural hematomas, subdural are not limited in their distribution and can be located above two and three lobes or over the entire hemisphere of the brain. In view of this ability to "spread out" in order to exert pressure on the brain, the subdural hematoma should have a larger volume compared to the epidural. Usually has a crescent shape. Often, two hematomas are formed: at the site of the traumatic agent and from the opposite side (as a result of the shock wave).

Acute subdural hematomas usually form without a clear gap, or it may be almost invisible. The general condition of the patient gradually worsens. There is a disturbance of consciousness, there are vegetative disorders in the respiratory and cardiovascular systems, which indicates the compression of the brain stem. Initially, the patient has cerebral symptoms in the form of severe headache, nausea and repeated vomiting. They are joined by symptoms of brain substance damage: a difference in the size of the pupils, a violation of sensitivity, speech disorders, pyramidal insufficiency. Possible convulsive attacks due to irritation of the cerebral cortex by hematoma. As the symptoms of compression of the brain increase, high blood pressure and rapid breathing, Slowed pulse is replaced by a drop in blood pressure, irregular breathing, acceleration palpitation.

Subacute subdural hematomas behave insidiously. At the time of rupture of the vessel and the outflow of blood, a loss of consciousness occurs for several minutes. Then consciousness is restored (or there is stunning), and there comes a light period, which can last up to 14 days. During this time, neurologic symptoms may be completely absent, patients complain of a mild headache, general weakness and increased fatigue, perhaps a slight increase in blood pressure and somewhat delayed palpitation. After a certain period of time, the patient develops psychomotor agitation, there are convulsions with loss of consciousness. There may be symptoms of speech impairment, muscle weakness in the opposite focus of hematoma localization of the limbs. On the side of the hematoma the pupil dilates and ceases to respond to light, indomitable vomiting arises, blood pressure rises, and the pulse slows down. The depth of the disturbance of consciousness grows to a coma. If the compression of the brain reaches the trunk, then incompatible with life disturbances of breathing and cardiac activity may occur, and the patient will die.

Chronic subdural hematomas occur several weeks or even months after the injury. Most often this happens in people older than 50 years. During the entire light period of the patients, headache, weakness and fatigue are periodically disturbed. Patients continue to lead a normal lifestyle, go to work. And then, in their opinion, for no apparent reason, there are signs of focal brain lesions. This can be a violation of strength in the limbs, illegibility or loss of speech, convulsive seizures, which resembles a picture of a stroke. Patients may not even focus on the fact of the craniocerebral trauma received a few weeks ago. Deterioration of the condition progresses, there is a violation of consciousness, changes in cardiac activity and respiration. Diagnosis is made on the basis of data of anamnesis and additional methods of investigation (computed tomography or magnetic resonance imaging).

Intracerebral hematoma

This type of hematoma means the accumulation of blood in the thickness of the brain tissue, that is, when the blood is impregnated with a portion of the brain. Usually, about 1/3 of the hematoma is the liquid part and 2/3 of the blood clots. Most often localized in the temporal and frontal lobes, slightly more rarely in the parietal. Have a rounded spherical shape.

Traumatic hematomas are located closer to the cerebral cortex, and vascular genesis (with hypertension, atherosclerosis) - in the depth of the brain.

Symptoms of an intracerebral hematoma usually arise almost immediately after a hemorrhage, as the nervous tissue immediately becomes impregnated with blood. These are gross focal features: the loss of the ability to reproduce and understand speech, loss of strength in the limbs (paresis), distortion of the face, loss sensitivity in some part of the body, loss of visual fields, violation of criticism to his condition, sudden mental disorder, violent violation coordination. Symptoms are determined by the location of the hematoma, the function of the affected nerve tissue falls out.

A characteristic feature of intracerebral hematomas is that they, even at small sizes, cause compression of the brain tissue. Therefore, for them there is a classification of their size (small hematoma - up to 20 ml, medium - 20-50 ml, large - more than 50 ml).

In addition to focal symptoms, there are signs of increased intracranial pressure and dislocation of the brain (displacement of structures). The displacement of the brain downward leads to the excision of the tonsils of the cerebellum into the large occipital foramen, the compression of the medulla oblongata. Clinically, this is manifested by nystagmus (involuntary trembling movements of the eyeballs), doubling and strabismus, and then the floating movements of the eyeballs, the difficulty of swallowing, the violation of the rhythm of breathing and cardiac activities.

If blood breaks through the ventricles of the brain, then the condition deteriorates sharply. The body temperature rises to febrile digits (38-40 ° C), consciousness is oppressed to a coma. There is a hormometry - a periodic convulsive contraction of muscles. Hemorrhage in the ventricles of the brain often leads to the death of the patient.

Diagnostics

Diagnosis of hematomas of the brain is based on the history of the disease, clinical symptoms (a special role is played by the presence of a light period after which progressive deterioration of the condition develops) and these additional research methods: echoencephalography, computed tomography (CT), magnetic resonance tomography (MRI).

Echoencephalography (echoencephaloscopy) with the help of ultrasound makes it possible to detect the displacement of the midline structures of the brain in the presence of any kind of hematoma. CT and MRI allow to determine the type of hematoma, its location, volume. These data become fundamental for determining the tactics of treatment.

Treatment of hematoma of the brain

Treatment of hematomas of the brain can be conservative and operative.

Conservative treatment is subject to small-size hematomas, provided there is no compression of the brain tissue and lack of the progression of hematoma sizes, that is, when there is no evidence of an increase in intracranial pressure and dislocation of the trunk the brain. Such patients are subject to strict medical supervision. Initially, drugs are used to stop bleeding from the damaged vessel (hemostatics), and a little later - to promote resorption of the hematoma. Diuretics (Diacarb, Lasix) are shown, which cause a decrease in intracranial pressure. If necessary, prophylaxis of thromboembolism and correction of blood pressure.

When there are signs of deterioration, increased intracranial pressure, worsening of the patient's consciousness, the tactics of management are revised towards surgical intervention.

Surgical treatment is indicated for patients with medium and large hematomas, signs of compression of the brain tissue. In most cases, neurosurgical operations are performed in an urgent (fastest, most immediate) order to have time to save the life of the patient and get him out of the pathological state with minimal consequences.

Types of surgical interventions:

• transcranial removal (with the help of trepanation of the skull);
• endoscopic removal of the hematoma.

In urgent conditions, trepanation of the skull is more common. It can be osteo-plastic (when a piece of bone is left connected with soft tissues and after the operation is put in place) and resection (when part of the skull bone is removed irrevocably, in this case there remains a defect that may require plasty in further). After opening the cranial cavity, hematoma is removed (sucked off), the wound is inspected, a bleeding vessel is found and coagulated. Moreover, when the epidural hematoma is removed, the integrity of the dura is not violated, which reduces the risk of postoperative infectious complications. After removal of blood clots, use hydrogen peroxide, a hemostatic sponge to surely stop bleeding. The wound is left with drainage.

Endoscopic removal of the hematoma is made through a small milling hole in the skull. Special operations are required for these operations. Such operations are less traumatic and faster recovery than conventional trepanation techniques. However, their conduct is not always possible, because through a small hole it is difficult to audit the wound, remove all the clots and even more so to detect the source of bleeding. The tactics of conducting operative treatment are determined in each case individually.

The effectiveness of surgical treatment largely depends on the timing of the surgical procedure. The presence of prolonged compression of the brain tissue and its dislocation significantly worsens the prognosis, because in In such cases, removal of the hematoma does not lead to a complete spreading of the brain tissue that has undergone compression. Sometimes in the affected areas develop secondary ischemic changes that are irreversible. Therefore, there is a direct relationship between treatment outcomes and the timing of operations.

Sometimes after surgical treatment there is a recurrence of the hematoma and then it is necessary to conduct repeated surgery.

After successful carrying out of operative treatment the patient is conducted antibiotic therapy, restoring drug therapy aimed at improving the metabolism of brain tissue, the restoration of lost functions. Usually 3-4 weeks are enough for this. With competent and timely treatment, it is possible to completely restore all impaired functions and recover without consequences. Otherwise, a person may lose his ability to work and become disabled.

Thus, brain hematoma is a rather severe neurological disease. It can manifest itself with various symptoms immediately after its onset, but can "hide" and make itself felt only after a few weeks or even months. In most cases, hematoma of the brain requires surgical treatment in urgent order, which allows saving the life of the patient and relieving him of disability.