Surgery for Brain Hemorrhage
Surgery For Brain Hemorrhage And Traumatic Brain Injury (TBI)

Dr. Ghaly comments:

Brain hemorrhage can be caused by several conditions. Commonly, trauma, a hit to the head or trauma to the head, such as in an accident, may cause the brain to hemorrhage. If the hemorrhage is of a special type, surgery is needed immediately to relieve pressure on the brain. The brain is encased in the skull, which usually protects it, but if the brain suffers a traumatic insult which causes swelling, there is no place for the brain to go and it is squeezed. The patient may feel OK for a while after the accident, perhaps even for several hours, while the swelling continues. But once it is enough to cause pressure on the brain, symptoms will start to appear. This is called herniation.

It is important to remember that the brain can only survive for about five minutes without oxygen or blood flow.

A second cause of brain hemorrhage is uncontrolled high blood pressure, especially when the upper number is 170 to 180 or even higher. This causes severe headache and pressure in the eyes, causing brain hemorrhage.

Third, people who are on blood thinners for other medical conditions may suffer brain hemorrhage. Drugs such as coumadin, Plavix, or even aspirin may cause brain hemorrhage. They need to be monitored very carefully.

Also problems in the circulatory system may cause brain hemorrhage, such as an aneurism. This happens in otherwise healthy people and onset of symptoms is very abrupt. If an aneurism is not diagnosed and treated early, before the hemorrhage, some 2/3 of patients will not have a successful outcome. Symptoms include a very severe headache. Patients are usually taken to an emergency room where a CAT scan reveals the aneurism, called a subarachnoid hemorrhage. Treatment is to place a stent-like coil device to open the blood vessel or immediate surgery.

Tumors, which bleed, may also cause a brain hemorrhage.

With all these conditions, without immediate treatment, deep coma followed by death is the outcome.

Treatment for brain hemorrhage should be immediate and aggressive and recovery may take weeks, months, or even years. Patients find their memory gone until the pressure is relieved, so they remember little of the event or treatment. Usually we see at least some improvement within the first three months after the insult to the brain.

A supportive and dedicated family and/or friends can be extremely important in the recovery of a patient stricken by a brain hemorrhage. The patient needs a supportive and committed family to care for them until the brain has a chance to recover. We find the family is usually the first to tell when the patient is making some progress in recovery. Often the healthcare provider will say the patient is in a deep coma, but the patient’s family will notice small improvements.

It is interesting to note that we have no objective method to predict which patient will recover, and which patient will not recover. So I advise aggressive treatment until the patient shows signs of gradual recovery. Patients, who show they are fighting to survive, who fight for life, and the other body systems are functioning, are usually the ones who recover. And recovery may take weeks, months, or years. There is just no test to tell us which patient will recover, so the physician needs to continue to hope. There are reports of patients recovering after months in a coma, and after healthcare providers have given up all hope of their recovery.

Brain death is one indication a patient will not recover, but even that can be difficult to determine. Brain death means:
  1. There is no blood going to the brain, which is determined by a blood flow study.
  2. There is no brain activity or function.
  3. There is no electrical activity within the brain.
  4. The patient shows no responses to stimulus whatsoever.
  5. The eyes do not open or respond to stimulus.
  6. There is no swallowing reflex
  7. There is no cough reflex.
  8. There is no response to auditory stimulus.
  9. There is no gag response.
  10. There is no movement.
  11. The patient cannot breathe by himself or herself.
  12. A CAT scan or MRI shows the brain is dead.
Even with the above indicators, testing should be done again in 24 hours time, and longer for children because they have more plasticity in the brain and may show signs of recovery even later. The physician also needs to make sure the brain death is not caused by medication, sedation, or cold, all things which may cause brain death.

In general, younger, healthy patients have a greater chance of recovery from brain hemorrhage. If we can control pressure to the brain, which can be measured by a measuring device placed inside the brain, and do surgery sooner, there is a better chance of a successful outcome. If the pressure continues to build, even after intervention, that is a bad sign.

Finally, it is important to remember that a patient is facing a long and difficult recovery after a brain hemorrhage. I tell patient’s families that their loved one will become like an infant, requiring extensive care again, just as they did when they we newborn. It takes vigilant care, both o the part of the healthcare provider and the patient’s family, to ensure a successful recovery. Like an infant, the brain cannot talk and tell you what is wrong, so the doctor has to anticipate and work hard to prevent any secondary insults to the brain. Secondary insults occur when other body systems begin to fail. Such things as kidney failure or pneumonia cause a secondary insult to the brain as it is trying to recover. All these can harm the brain while it is trying to recover from its initial insult, the hemorrhage. Our goal as physicians is to maintain a healthy body until the brain can recover.

The family needs to continue their commitment to the patient’s care for up to a year or longer. These, in my experience, are the patients who do well. Usually, the fighters for the patient are family members. There is also an increasing confusion that the patient would want to terminate life if there are questions of what the quality of that life might be after recovery. It is impossible to determine what the quality of life will be, as no one can predict who will recover, and who will not. There is nothing absolute about who will recover. So my fear is that we are terminating life prematurely in many cases.

In addition, it is my experience that patients who might say when they are perfectly healthy they would not want to live a disabled life often change their minds. I had a patient who told his wife he would not want to live if he could not walk his dog. He suffered a brain hemorrhage, and his wife agreed to the surgery. The man is confined to a wheelchair today, seven years later, but he has told his wife he is glad she went against his expressed wishes and opted for aggressive treatment.

The fact remains, at the time of the insult to the brain, we cannot be sure of a lot of the end results.

Further comfort may be taken in the fact that the patient does not report suffering while in a coma. In my experience there is no suffering during a coma. We have never had a single patient wake from a coma and say they suffered. The family suffers when their loved one is in a coma, but not the patient. This is a gift from God. The patient’s memory starts after they wake up from the coma.

I always caution people about a DNR (do not resuscitate) order or advanced directive. My fear and my observation has been that these things are used by medical facilities to relax treatment, preventing the aggressive treatment so necessary for a recovery. I strongly advise the patient needs to continue aggressive treatment until clearly there is no hope of recovery: there is no activity in the brain; there is an anoxic response; there is no auditory or visual response; no reflexes; and the CAT/MRI shows a major insult, especially to the dominant side of the brain (the left side for a right handed person, which controls cognition).

It is my opinion that aggressive treatment for the brain should be continued. If it is God’s will for the patient to recover and live, it is prudent to stand by the person and provide treatment. There are many ways for the patient to die after a brain hemorrhage. If it is God’s will for the patient to die, it will be so. But the patient’s family should be committed caregivers early on to ensure every possibility for a good outcome and recovery.

The family should always look for the small improvements, with a glass half full attitude. Be positive. Keep a diary and take pictures. You’’’ share that diary with the patient once they awaken. The diary will also be helpful in teaching family members how to care for the patient. I know of one patient, whose family shared eight-hour shifts at the hospital, keeping a lap top computer in the room on which to record the care and responses of the patient during each shift.

The family is really the best advocate for the patient. There is nobody who takes as good care of a patient as his or her family. Sadly, often the patient becomes a number to the healthcare providers. But the family always places the patient and his or her care first.

Be aware also of how the healthcare system works, Ancillary services, such as physical or occupational therapy, and insurance companies have developed terms, which if taken literally, can be disappointing, as well as affecting patient care. Plateau is one such term. If a patient is said to have reached a plateau, the patient is said to be no longer improving, and the insurance company will terminate care. A plateau does not mean the patient will never make more strides to recover. Many brains will continue to recover for years. Remember it takes an infant brain 18 years to develop into an adult brain. If we wait long enough and keep the rest of the body healthy, many patients will eventually further improve, even after years. I had a patient who was paralyzed from a major stroke and seven years later he began to be able to move. Just as a baby needs a mother to care for it for many years, so, too, a brain which has been injured from a brain hemorrhage needs care, often for many years as well.