Prof. Dr. Mehmet Şenoğlu — Brain, Nerve and Spine Surgery
Among the situations for which a brain surgeon is most often called in the middle of the night, head traumas and brain hemorrhages come first. These are emergency pictures in which minutes sometimes determine a person’s life, and sometimes the quality of that life. In my office or in the emergency department, the question an anxious relative most often puts to me is this: “Doctor, he hit his head but looked fine, then he suddenly got worse. How can that be?” The answer to this question actually explains why brain hemorrhages are such insidious situations, and why they must be taken so seriously.
In this article, I want to explain in clear language what brain hemorrhages are, their types, which symptoms call for going to the hospital without delay, and how emergency surgical approaches save lives. My aim is not to create fear; it is to emphasize the importance of taking action at the right time, with the right information.
The Skull: A Structure That Protects, but at the Same Time Confines
The key to understanding brain hemorrhages lies in grasping the nature of the skull. The skull is a solid and closed box that protects our brain from blows. However, this closedness at the same time creates a disadvantage: the space inside is fixed.
Three things are found inside the skull: brain tissue, cerebrospinal fluid, and blood. The total volume of these three is fixed. When a hemorrhage begins inside the head, the accumulating blood takes up space; but because the box cannot expand, this extra volume begins to press on the brain tissue. This is exactly what makes brain hemorrhages so dangerous: as much as the hemorrhage itself, the increase in pressure it creates also poses a threat to life. If this pressure is not brought under control, it can press on the brainstem and stop the respiratory and circulatory centers.
What Is a Brain Hemorrhage?
A brain hemorrhage is the filling of blood into an area where it should not normally be, as a result of a vessel inside the skull rupturing or becoming damaged. We can gather them under two large headings:
- Traumatic hemorrhages: These occur as a result of a blow taken to the head — such as a fall, a traffic accident, or an impact.
- Spontaneous (non-traumatic) hemorrhages: These develop on their own, without a blow, mostly for reasons such as high blood pressure, an aneurysm, or a tangle of vessels (AVM).
In this article, I will mainly address trauma-related pictures; however, I will also touch on spontaneous hemorrhages, because the two are often intertwined.
Types of Brain Hemorrhage
Where the hemorrhage accumulates determines both the symptoms and the treatment approach. The types we encounter most often in head traumas are as follows:
Epidural Hematoma (Between the Skull and the Brain Membrane)
This is a hemorrhage accumulating between the skull and the outermost membrane of the brain (the dura). It generally occurs as a result of a skull fracture rupturing an artery. Because it is of arterial origin, it can accumulate quickly and create a threat to life in a short time.
This picture has a classic and insidious feature: the “lucid interval” (the clear period). After the blow, the patient remains unconscious for a short time, then comes to and looks fine; but as the blood accumulates, they rapidly deteriorate within minutes or hours. The situation relatives describe as “he was fine, then he suddenly collapsed” is most often this. For this reason, “looking fine” after a head trauma is never a guarantee.
Subdural Hematoma (Beneath the Brain Membrane)
This is a hemorrhage that occurs as a result of the rupture of the bridging veins between the brain membrane (the dura) and the brain. Because it is generally of venous origin, it can develop more slowly than the epidural type. It presents to us in three forms:
- Acute subdural hematoma: It appears immediately after a severe trauma; it is a serious picture.
- Subacute: It becomes apparent days after the trauma.
- Chronic subdural hematoma: It is seen especially in the elderly, those using blood-thinning medications, and those with alcohol dependence. Sometimes it begins with a blow so mild that the patient does not even remember hitting their head. The symptoms appear slowly over the course of weeks.
Intracerebral (Within-the-Brain) Hematoma
This is the type in which the blood accumulates directly within the brain tissue. It can be due to trauma, but it also develops most often due to high blood pressure. Depending on which region of the brain it is in, it can lead to loss of speech, movement, or consciousness.
Subarachnoid Hemorrhage (SAH)
This is the filling of blood into the space between the thin membranes surrounding the brain. It can be seen after trauma, but in non-traumatic situations it mostly occurs as a result of the rupture of a brain aneurysm. A suddenly starting pain, described as “the most severe headache of my life,” is the classic warning sign.
Symptoms: What Should One Watch For After a Head Trauma?
Never take lightly the following symptoms that may appear after a head trauma. If even one of them is present, one should go to the nearest emergency department without loss of time:
- A progressively increasing, severe headache
- Repeated vomiting (especially of a projectile kind)
- Change in consciousness: Drowsiness, excessive sleepiness, difficulty being woken
- Confusion, impairment of speech, absent-mindedness
- Loss of strength, numbness, paralysis in an arm or leg
- A seizure
- The pupils being of different sizes (one large, the other small)
- Blurring of vision or double vision
- Loss of balance, being unable to walk
- Clear fluid or blood coming from the nose or the ear
In children, additionally: constant crying, restlessness, refusing to feed, and a bulging fontanelle in infants are signs that need attention.
An important reminder: These symptoms may not appear immediately after the trauma. Sometimes, even if the first tomography looks clean, the picture can change within hours. For this reason, those who have suffered a severe head trauma should be kept under observation for a while.
How Is the Diagnosis Made?
In head trauma, the fastest and most valuable tool for diagnosis is computed tomography (CT). Within a few minutes, it shows skull fractures, the hemorrhage, and how much the brain is under pressure. This is the first method turned to in the emergency department.
Here I must emphasize an important point: Sometimes the first tomography taken may not fully show the hemorrhage, because it is still very thin. However, if the patient’s condition is worsening, the tomography is repeated a few hours later. This is exactly why saying “the tomography came out clean” does not mean “the danger has completely passed”; observation is of vital importance.
When needed, MRI (for finer details), angiography (in cases of suspected aneurysm or a vascular problem), and blood tests (especially to assess the clotting status) come into play.
Does Every Brain Hemorrhage Require Surgery?
No — and this is a commonly misunderstood subject. The type, size, and location of the hemorrhage and the patient’s condition determine the treatment.
Small hemorrhages that do not create pressure and do not impair consciousness are most often monitored without surgery. During this process, the patient is closely followed; with repeated tomographies, it is checked whether the hemorrhage is growing, and brain edema and intracranial pressure are kept under control with medications. The body can dissolve small hemorrhages on its own over time.
However, some situations require emergency surgery. The decision to operate is generally made in the following situations:
- The hemorrhage being large and making a marked pressure on the brain (displacement of the brain structures — “shift”)
- The level of consciousness being impaired or progressively worsening
- Progressive neurological losses (such as loss of strength or paralysis)
- Intracranial pressure being impossible to bring under control
Emergency Surgical Approaches: A Race Against Time
The most valuable thing in brain hemorrhage surgery is time. A correct intervention performed in the early period, which we call the “golden hours,” both saves life and reduces the risk of permanent damage.
Craniotomy
This is the most frequently applied method. A bone window is opened in the planned region of the skull; the accumulated blood clot (hematoma) is cleared, and the vessel causing the hemorrhage is found and stopped. This piece of bone is most often placed back at the end of the procedure. It is life-saving especially in epidural and large subdural hematomas.
Burr Hole (Making a Hole / Trepanation)
This is a smaller procedure, applied especially in chronic subdural hematomas. One or several small holes are opened in the skull, and the liquefied old blood is drained. It is a method we apply frequently in elderly patients, whose results are generally very good.
Decompressive Craniectomy
It is applied in severe cases where the brain edema is very intense and the intracranial pressure cannot be controlled otherwise. A portion of the skull is temporarily removed; in this way, room is made for the swelling brain to expand, and pressure on the brainstem is prevented. The removed piece of bone is put back in place once the edema recedes (generally weeks to months later) (cranioplasty). This, even though its name may sound frightening, is a life-saving intervention in severe traumas.
Intracranial Pressure Monitoring
In some severe trauma patients, the intracranial pressure is continuously monitored with a sensor placed inside the brain. This is very valuable in guiding treatment.
In all these procedures, neuronavigation, the microscope, and modern intensive care support have improved the results markedly compared with the past.
The Period After Surgery and Recovery
After brain hemorrhage surgery, the patient is generally monitored closely in intensive care; the state of consciousness, the pupils, and neurological findings are assessed regularly. The recovery process varies very greatly from person to person according to the type of the hemorrhage, the damage it has done to the brain, and the patient’s age and general condition.
Here I must be honest: The outcome depends, most of the time, not so much on the size of the hemorrhage as on how much the brain tissue beneath it has been damaged. After the blood is drained and the pressure relieved with surgery, if no permanent damage has occurred in the brain, the patient can return to their normal life. However, in severely damaged cases, physical therapy, speech therapy, and neurological rehabilitation may be part of a long process. Thanks to the brain’s capacity to adapt (neuroplasticity), notable improvements can be seen during this process; patience and regular rehabilitation are very important.
Who Is at Higher Risk?
- The elderly: The slight shrinking of the brain tissue with age puts the bridging veins under tension; even small blows can lead to a chronic subdural hematoma.
- Those using blood-thinning (anticoagulant) medications: The risk and severity of hemorrhage increase. If you use these medications, take even the smallest head trauma seriously.
- Patients with high blood pressure: They are at risk especially for spontaneous within-the-brain hemorrhages.
- Those with alcohol dependence: Both the risk of falling and the tendency to hemorrhage increase.
- Those with a bleeding disorder.
What Can You Do to Protect Yourself?
- Use a seat belt in the vehicle, and a helmet on a motorcycle and bicycle. These simple measures are the most effective preventers of severe head traumas.
- Prevent falls in the home: Especially in the elderly, non-slip rugs, good lighting, and grab bars in the bathroom save lives.
- Keep your blood pressure under control.
- If you use blood thinners, do not skip your doctor’s check-ups.
- After a head trauma, do not brush it off by saying “I’m fine”; especially if the above symptoms are present, be sure to get evaluated.
In Which Situations Should One Go to the Emergency Department Immediately?
If any of the following is present after a head trauma, go directly to the nearest emergency department without waiting for an appointment:
- Experiencing a loss of consciousness (even if brief)
- A progressively increasing severe headache
- Repeated vomiting
- Difficulty being woken, excessive sleepiness
- Impairment of speech, confusion
- Loss of strength or paralysis in an arm or leg
- Having a seizure
- The pupils being of different sizes
- Clear fluid/blood coming from the nose or the ear
- In children, constant crying, restlessness; in infants, a bulging fontanelle
Remember: In brain hemorrhages, early intervention very markedly increases the chance of both survival and preserving neurological functions.
Frequently Asked Questions
Below, I have gathered the most frequently asked questions about brain hemorrhages and head trauma along with brief answers. These answers are for general information; the information that applies to your specific situation is the one given by the physician who evaluates you or your relative.
I hit my head but I look fine — should I still go to the emergency department?
“Looking fine” after a head trauma is not always a guarantee. Some hemorrhages (especially epidural hematoma) give symptoms within hours; the patient can be fine at first and then suddenly deteriorate. If you experienced a loss of consciousness, if there are symptoms such as an increasing headache, vomiting, or sleepiness, or if you use blood thinners, you should definitely be evaluated.
What is the most dangerous symptom of a brain hemorrhage?
Impairment of the level of consciousness is the most important warning: progressively increasing sleepiness, difficulty being woken, confusion, or unresponsiveness. In addition to these, projectile-type vomiting, the pupils being of different sizes, and a seizure are also signs that require emergency intervention.
Does every brain hemorrhage require surgery?
No. Small hemorrhages that do not create pressure and do not impair consciousness are most often monitored without surgery, with close follow-up; the body can dissolve these over time. Surgery is needed in situations where the hemorrhage is large, is making a marked pressure on the brain, the level of consciousness is impaired, or neurological losses are progressing.
What is the difference between an epidural and a subdural hematoma?
An epidural hematoma forms between the skull and the brain membrane, generally through the rupture of an artery, and can accumulate quickly. A subdural hematoma, on the other hand, forms between the brain membrane and the brain, mostly through the rupture of the bridging veins; it can be acute, subacute, or chronic. Chronic subdural hematoma can develop especially in the elderly and those using blood thinners, even with mild blows.
What is a chronic subdural hematoma, and why is it seen more often in the elderly?
It is a hemorrhage that accumulates slowly beneath the brain membrane. Because the brain tissue shrinks slightly with age, the bridging veins come under tension and can rupture even with a small blow. Sometimes the patient does not remember hitting their head; the symptoms appear slowly over the course of weeks. It is generally drained with a surgery done through small holes (burr hole), whose results are mostly good.
Does a patient return to their normal life after brain hemorrhage surgery?
This depends largely on how much the brain tissue has been damaged. After the blood is drained and the pressure relieved, if no permanent damage has occurred, the patient can return to their normal life. In severely damaged cases, however, physical therapy and neurological rehabilitation may be part of a long process. Only the team following the patient can tell the exact course.
I use a blood-thinning medication and I hit my head. What should I do?
If you use blood thinners, you need to take even the smallest head trauma seriously, because the risk and severity of hemorrhage increase markedly. Even if you look fine, I recommend that you go to the emergency department without loss of time. Do not stop your medication on your own; this decision should be made only by the physician who evaluates you.
My child fell and hit their head — what should I watch for?
In children, loss of consciousness, repeated vomiting, constant crying or restlessness, difficulty being woken, unsteadiness, a seizure, and, in infants, a bulging fontanelle are signs that need attention. If any of these is present, or if there is a change in your child’s behavior that worries you, go to the nearest emergency department without delay.
Disclaimer (Legal Notice)
The information contained in this article has been prepared for general informational purposes only and in no way replaces a medical examination, diagnosis, or treatment. Brain hemorrhages and head traumas are emergencies; the diagnosis, treatment, and decision to operate vary greatly according to the type, size, and location of the hemorrhage and the person’s general state of health, and can only be determined by a team of doctors who evaluate the patient. If a head trauma or the emergency symptoms mentioned above are present, go to the nearest emergency department without loss of time. This article should under no circumstances be used to delay seeking emergency medical help.