About an intracerebral hemorrhage
In the event of an intracerebral hemorrhage, blood is present in the brain tissue. You will be admitted to the ER to treat the effects of the hemorrhage.
Symptoms of intracerebral hemorrhage include: acute and severe headache, nausea, neurological deficits, and reduced consciousness or loss of consciousness.
The course and prognosis of the hemorrhage depends very much on the cause and severity.
CausesAn intracerebral hemorrhage at a young age can have various causes, such as high blood pressure (hypertension), vascular abnormalities, or a brain tumor.
Disorders of the brain vessels that cause intracerebral hemorrhages most often at a young age are:
Admission to hospital
If you are admitted to hospital because the doctors think you have a cerebral hemorrhage, a CT (Computer Tomography) scan of the brain will be taken. This allows the doctor to see what kind of cerebral hemorrhage you have had. The blood vessels can be seen in the CT scan by injecting contrast medium into your arm via an IV, so that the doctor can detect any vascular abnormalities. A cause is often not found on a CT scan of the cerebral blood vessels.If there is any doubt about the cause of the hemorrhage, the team of vascular specialists may decide to conduct further tests. This is done by means of a vascular examination (angiography).
You will be admitted to the Intensive Care, Medium Care, or Stroke Unit if accurate monitoring and support of important bodily functions is necessary. Examples are respiration, blood pressure support, observation of the pressure in your head, or the heart rhythm. If your situation allows for it and you do not need continuous monitoring or support for bodily functions, you will be transferred to the nursing ward.
If the situation permits, you will be admitted to the nursing ward. You will typically stay in a single room. You will be checked regularly and your bodily functions will be monitored. We offer as much peace and safety as possible. As your situation becomes less pressing, the medical team at the nursing ward will map out the problems that remain after the hemorrhage, and speak with you and your loved ones about how and where you can best recover from the bleeding.
You will be cared for and observed by a specially trained nurse. This nurse is responsible for observation and care, and for the coordination of care.
A doctor is available 24 hours a day for the medical treatment, under the supervision of a medical specialist from the department. The medical specialist and the doctor in the department are in contact on a daily basis to discuss your treatment and policy. Every morning the doctor will visit you during visitation rounds in the ward and they will check with you and the nurse regarding your treatment progress. You will hear the results of the tests during the visit. If new tests are planned, the nurse will give you verbal and written information. If needed, an additional meeting with the doctor can be planned.
The effects of the ICH may be different. There may be hemiplegia (paralysis on one side), difficulties with swallowing and speech, and cognitive issues (difficulty thinking). That is why you will meet therapists in the various departments who will map out and treat the consequences of the ICH for your general function.
The treatment team consists of several professionals. They consult with each other. The goal is for you to receive guidance and information from the same people as much as possible during the admission.
The treatment team consists of:
- Treating neurosurgeon/neuro-intervention specialist: the doctor performing the treatment.
- Departmental physician: present at the IC, MC, or nursing ward from Monday to Friday from 9:00 am to 5:00 pm. They responsible for the implementation and continuity of daily medical care. A doctor is available 24 hours a day in the nursing ward.
- Intensivist: the doctor who treats you in Intensive Care. This doctor is available 24 hours a day.
- Nurse: responsible for the coordination of care, monitors you, assists you in your daily care, administers medication, and carries out actions on behalf of the doctor.
- Nursing specialists: monitors continuity, helps you think about your recovery process, is your contact person, and performs outpatient check-ups. During these check-ups, they will map out your complaints, discuss the influence of the complaints on your daily activities and, if necessary, refer you to the correct professional.
- Rehabilitation doctor: coordinates the care of co-treating therapists such as those who assist with speech therapy, physiotherapy, and occupational therapy, and advises you on your recovery process.
- Physiotherapist: treats problems regarding movement, breathing, coughing, or recovery.
- Speech therapist: treats problems with swallowing or speaking. You will also be treated by the speech therapist if you have a breathing tube (trachea cannula).
- Occupational therapist: identifies problems in daily function and can, if necessary, provide adaptive aids (e.g. wheelchair).
- Dietician: gives advice in the event of problems with nutrition or the nutritional situation.
- Social worker: provides support when there are social or societal problems, such as problems caused by legal incapacity or possible financial consequences of the disorder.
- Pastoral care staff: can support you and your loved ones in matters regarding spiritual and philosophical meaning.
- Transferpunt Zorg: the healthcare referral center, which arranges home care, care aids, or accommodation in a nursing home after hospitalization.
You may be confused and restless because of an ICH and this can lead to unsafe situations. To ensure your safety, it is sometimes necessary to use wrist, ankle, and abdominal straps made of fabric. These measures are generally not considered to be pleasant. If these measures are necessary, we will discuss them with you and your contact person.
After an ICH, all patients receive a number of medications such as painkillers, medication that improves the blood circulation in the brain, and medication to promote bowel movement.
Home medication such as blood thinners and antihypertensives (blood pressure medications) are usually stopped. You can continue to use other medication.
TreatmentIf you have increased intracranial pressure as a result of the cerebral hemorrhage, the doctor will consider placing a shunt and a pressure gauge through the skull into a ventricle of the brain. This enables cerebrospinal fluid to run out and reduce the pressure in the brain. Intracranial pressure may also be measured. You will be admitted to the Intensive Care Unit, the Medium Care Unit, or Stroke Unit.
If the hemorrhage occupies a large area and the brain is pushing itself against the skull, the doctor may consider removing the hemorrhage surgically. If extreme swelling of the brain occurs, part of the skull may temporarily be removed during the swelling period. The missing part of the skull can be replaced after 3 months if you have recovered sufficiently. During the recovery period, you will be fitted with a helmet to protect the brain.
The intensivist and the neurosurgeon discuss the treatment plan with your contact person.
Hydrocephalus is the accumulation of cerebrospinal fluid in the ventricles of the brain. Hydrocephalus can develop acutely if the bleeding causes the passage between the ventricles of the brain close and the cerebrospinal fluid cannot drain out. It can also develop gradually when the relatively large blood cells stop the drainage of the water-thin cerebrospinal fluid. The "drain" then becomes clogged, which causes the pressure in the brain to increase. Due to the high pressure in the brain, the patient is always suffering from drowsiness, and there may be a downward pressure on the eyes or narrow and non-responsive pupils. Usually there is an increase in headache, nausea, and vomiting.
In that case, cerebrospinal fluid drainage is required. You can read more about this under the heading Cerebrospinal Fluid Drainage.
The brain and spinal cord are surrounded by cerebrospinal fluid (liquor). Cerebrospinal fluid has several important functions, specifically:
Cerebrospinal fluid looks like water and is produced in the cavities of the brain, which are called the ventricles. There are two side ventricles (lateral), a third ventricle in the center of the brain, and a fourth ventricle at the bottom of the cerebellum. Cerebrospinal fluid is continuously created and absorbed. On average, cerebrospinal fluid is completely renewed about 3 to 4 times a day.
- Protection of the brain. The brain is surrounded by the cerebrospinal fluid and can therefore not come into contact with the skull. The cerebrospinal fluid also protects us against the absorption of toxic substances into the blood.
- Passing information from the brain to other cells in our body.
Why a shunt?If the circulation of the cerebrospinal fluid does not run smoothly, the fluid will accumulate in the brain. Accumulation of cerebrospinal fluid increases the pressure in the brain. This can disrupt the function of the brain and damage it. If cerebrospinal fluid accumulates, the doctor must do something to limit the damage as much as possible.
TreatmentExternal ventricular drainVentriculoperitoneal shunt (VP shunt)
An external ventricular drain (EVD) is a thin tube (drain) that is surgically placed through your skull into the ventricle. During surgery, the doctor will make a small incision in your skin. An incision is made in the cranium with a diameter of about 1 cm. A piece of the drainage tube is then inserted into the ventricle of the brain. After that, the skin is closed and the drainage tube is secured by means of a suture or bandage.
Because the drainage collection system is attached to your bed, you will be on bed rest. The doctor determines where the collection system will be attached.
If the absorption of the cerebrospinal fluid is a long-term problem, a ventriculoperitoneal shunt (VP shunt) is an option. This shunt helps drain the cerebrospinal fluid. The shunt is a tube that the doctor inserts into the ventricle of the brain. From here the shunt runs internally to your abdomen. The shunt has a pressure control valve. This valve is located under the scalp and can be felt above the right ear. It ensures that cerebrospinal fluid is discharged to the abdomen via the shunt if the pressure in the head becomes too high. When the pressure in your head has returned to normal, the drainage of cerebrospinal fluid stops.
The placement of this shunt is done during an operation. It is a fairly simple procedure. The doctor drills a hole into the right side of the skull. Through this hole, they will place the shunt into the ventricle of the brain and slide it under the skin towards the abdominal cavity. The operation takes about an hour.
ComplicationsThere is a risk of complication with every surgical procedure. The most common complication with a VP shunt is an infection, or insufficient function of the shunt. Your attending physician will discuss the possible complications of this operation with you.
Delirium often occurs after a brain hemorrhage. It is a state of confusion that is accompanied by hallucinations or unrealistic ideas, often with anxiety and fear, but sometimes with apathetic and silent behavior. Characteristic symptoms of delirium are alternating levels of consciousness and worsening of the symptoms during the course of the evening and night. Delirium after a cerebral hemorrhage can be caused by the bleeding, an infection, or disruption to metabolism.
If the cerebrospinal fluid is drained through an external shunt, there is a risk of bacterial meningitis. A urinary catheter also causes rapid urinary tract infections and lying on the bed for long periods of time on the ventilator causes the risk of a lung infection. With a longer hospital stay, resistance is lowered and the risk of infection increases. If there are signs of an infection, for example due to fever or increased inflammation in the blood, then cultures are taken to determine the cause of the infection and to identify the bacteria, so that we can treat you with the right antibiotics. This is done in consultation with the medical microbiologist.Fever after a cerebral hemorrhage also occurs frequently without bacteria being the cause. We think this occurs because the regulation of body temperature in the brain is disturbed.
After an intracerebral hemorrhage, various cardiac dysrhythmias (rhythm abnormalities) can occur, which usually recover on their own. A heart that has already had issues maintaining its pumping function may find it difficult to process the additional amount of fluid being administered after a cerebral hemorrhage. This can cause heart failure. This, or the bleeding, can cause fluid to accumulate in the lungs, making it more difficult to breathe or be taken off artificial respiration.
Lying still in bed can cause thrombosis. If this dislodges, a blood clot can end up in the lungs. This causes acute deterioration and shortness of breath.
In order to avoid the above problems, bed rest precautions are taken: such as pneumatic stockings, cycling in bed, bed mobility, or sitting in a chair as soon as possible.
Discharge from hospital
In the course of admission to the nursing ward, the neurosurgeon's medical treatment gradually tapers off. Your stay will be more about rehabilitation.
During recovery, your medical team will advise you on the best place to recover after hospitalization.
Discharge to homeIf daily function can be resumed independently and safely, you can go home after your discharge. Your family or friends can pick you up at the agreed upon time. For example, if you still require therapy at home, you will be referred to a practice for physiotherapy or occupational therapy. If you need care, the nurse will fill out a request for home care. An expert from the Centrum Indicatiestelling Zorg (Care Assessment Centre - CIZ) will give you advice about the care you need at home.
After some time you may notice at home that you have problems with fatigue, irritation processing, concentration, or memory. This will be discussed during the aftercare consultations and you may still be referred for daytime treatment in a rehabilitation center.
Rehabilitation at a rehabilitation centerFor rehabilitation at a rehabilitation center (Medical Specialist Rehabilitation) there must be sufficient capacity and the prospect of a future discharge to the home. If this is chosen, the rehabilitation doctor will register you for this type of rehabilitation. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being.
Rehabilitation in a nursing homeIf your strength is so limited that you still need a lot of rest between therapy sessions and there is a prospect of a future discharge to the home, you can opt for the Geriatrische Revalidatie Zorg (Geriatric Rehabilitation Care, GRZ) at a nursing home. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where GRZ is possible, and takes care of the registration.
Long-term rehabilitation in a nursing homeIf there is still a lot of support needed for daily activities and it is uncertain whether discharge to the home is still possible, a long-term stay with rehabilitation at a nursing home is an option (care indication 9b). The patient will have a longer period of time to recover and, if possible, discharge to the home is an option. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where it is possible to stay for care indication 9b.
Vroege Intensieve Neurorevalidatie (Early Intensive Neurorehabilitation - VIN)VIN is an intensive rehabilitation program for patients who have suffered serious brain damage and are therefore in a state of impaired consciousness. The VIN program can make a significant contribution to the restoration of consciousness. There are only a few centers in the Netherlands where this program is employed. In the south of the Netherlands this is Libranet, the Leijpark location in Tilburg. The care indication is determined by the rehabilitation physicians of the institution.
Long-term stay in a nursing homeIf self-care is largely taken over and your doctors expect that you will not recover sufficiently to return home, you may be admitted to a nursing home for a long period of time. This is rare in younger patients with a brain hemorrhage. After completion of the neurosurgical treatment, it is possible that you will be transferred during the waiting period, for the time being, to the regional hospital where you were initially taken care of. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where a long-term stay is possible.
If you are discharged and you do not need nursing care during the transport, your loved ones may pick you up from the nursing ward.
If you are transferred to another institution and need nursing care during your trip, the nurse in the department will arrange for you to be transported by ambulance.
The nurse gives the medical and nurse transfer to the ambulance attendant. Your general practitioner will receive a letter stating what treatment you have had.
Rehabilitation aimed at improving complaints and limitationsBrain damage can cause many different complaints, such as loss of strength, memory problems, difficulty speaking, or spasticity. Rehabilitation is aimed at reducing the symptoms and problems in order to be able to function as well as possible again. read more
Rehabilitation aimed at improving complaints and limitations
This can sometimes be with a primary care practitioner, i.e. a therapist in the neighborhood. If there are problems in more areas, treatment by a rehabilitation team led by a rehabilitation doctor is usually necessary. You can then be admitted to a rehabilitation center or follow a day treatment program from home in a rehabilitation center.
The rehabilitation doctor may treat spasticity with medication or injections. Speech and language problems are treated by a speech therapist. Cognitive and mood problems are examined and treated by a neuropsychologist. The rehabilitation team often pays attention to resuming work after a stroke at a young age.
Rehabilitation at a later stageSometimes problems caused by the brain injury only become apparent after a long period of time. In this case as well, the general practitioner, neurologist, neurosurgeon, or nurse specialist can refer you for treatment by a therapist in the neighborhood, the treatment program Hersenz, or a rehabilitation doctor. Problems that only become apparent after a longer period of time often consist of behavioral changes and cognitive issues, such as difficulty with memory, planning, or dual-tasking and slow thought. This often requires specialized rehabilitation.
AftercareIn the Netherlands, aftercare is arranged differently for each hospital. In many hospitals this is done at the aftercare outpatient clinic, but it can also be arranged through a home care organization or through rehabilitation. Often, there are regional agreements on this matter. You can contact your therapist for this.
In most treatment centers you will be scheduled for an appointment with a nurse specialist or specialized care provider from the aftercare outpatient clinic after the admission. They discuss the questions and problems that have arisen after the hemorrhage. For example, problems with memory, attention, concentration and fatigue, side effects of medication, or new complaints. As a rule, this person is also available for questions. They can give advice or refer you to an organization that can support you in this. Attention is also paid to the presence of risk factors for cerebral hemorrhage such as high blood pressure, smoking, and obesity.