The first word we hear from the average person when an individual complains of a massive headache, collapses, and dies in a matter of days is "aneurysm". A relatively common bleed in the third compartment of the brain from which nearly everyone of us has had a friend or relative die.
However, according to Dr Azad Esack, a consultant neurologist, there are really four types of Intracranial Bleeds in the head from which bleeding can occur in several areas, so that a patient who collapses and dies from a brain hemorrhage could have suffered from any of the four and not necessarily an aneurysm, which is caused by a rupture of a congenital defect in the wall of a blood vessel in the brain. Stress, for instance, can cause a rise in blood pressure which puts pressure on the already weak system and gives rise to this bleed.
The "Aneurysm" and "Aterio-Venous Malformation" described as a abnormal collection of blood vessels may both give rise to one of the types, Sub-Arachnoid Bleeding.
An "Intracerebral Bleed" described as bleeding into the brain substance itself is usually secondary to hypertension, and results from a ruptured small blood vessel. And lastly, "Subdural" and "Epidural Bleeds" are usually the result of trauma (injury to the head). In the first instance, sub bleeding under the dura, the brain's tough covering, can push the brain to one side, while an epidural bleed occurs between the skull and the dura - outside of the dura.
What our parents and grandparents very blithely called a Cerebral Hemorrhage in the old days could result from any of the four intracranial bleeds mentioned above. However, says Dr Esack "it is fairly easy to determine where the intracranial bleed is located through a brain scan."
The neurologist, a doctor who has specialised in the medical diseases of the nervous system, looks after patients with strokes, epilepsy, Parkinson's Disease, back pain, multiple sclerosis, headaches, dizziness, nerve and muscle disease and degenerative diseases of the brain; and will refer patients who need surgery to the neuro surgeon.
Although most times we are told that our friend or relative simply complained of a very bad headache and collapsed, it is said by a Scottish consultant neurosurgeon, Dr Gillingham, that about fifty percent of the patients get a warning headache prior to a sub-arachnoid bleed. But the main symptom of this type of bleed is a severe headache which has been described as "if struck by a cricket bat at the back of the head. It is sudden and often accompanied immediately by vomiting. In addition, the patient may blackout or even become comatosed" says Dr Esack, who warns that it is not the intention to scare people since at any one point in time one in ten people have headaches: "Are they all going to get sub-arachnoid bleeds?. If you have someone who is not a headachy person and suddenly has a severe headache that is the person you want to reach out to."
In the case of an intracerebal bleed which carries a mortality rate of about 40%, patients need to have their blood pressure monitored and treated and as well medication to deal with the effects of the bleed on the brain which becomes swollen. In a few selective cases, there may be an operative option. The highest time of mortality here is the first few days after the bleed. The patient may go into a coma depending on the size of the bleed.
Sub-Arachnoid bleeds carry about a 60% mortality rate overall. The majority of these bleeds are due to the rupture of an aneurysm, usually situated at the bifurcation (the point where the vessel splits into two) of a blood vessel.
There can be numerous complications, the majority of which arise in the first two weeks after the bleed include vasospasm - the blood vessel gets smaller and less blood gets to the brain; rebleeding- the blood clots in the first two weeks but there is nothing to say it will not bleed again; hydrocephalus- the enlarging of the fluid compartment for the brain; electrolyte imbalances- alterations in the sodium levels affecting the blood with its two syndromes - diabetes insipidus causes a significant rise in the urine output, and the syndrome of inappropriate anti-diuretic hormone secretion where the sodium level in the blood falls significantly; and a bleeding peptic ulcer.
In terms of investigation, a cerebral angiogram will define the extent of the bleeding and depending on the condition and age of the patient there could be surgery to clip off the aneurysm or nowadays a coil could be inserted into the neck of the aneurysm through a cathether into the brain , although this is not yet available in Trinidad and Tobago.
"At the end of the day" warns Dr Esack "if you are not a headachy person and you have experienced a significant headache, especially if accompanied by nausea or vomiting, then you ought to seek medical attention."