Spontaneous brain haemorrhage is a subset of stroke. Haemorrhage may be into the brain (intracerebral haemorrhage) (8% of stroke) or into the subarachnoid space (5% of stroke).

Finding and treatment of the underlying cause can prevent future bleeds, and reduces death and disability.

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Arteriovenous malformations (AVM) are the commonest cause of spontaneous brain haemorrhage in the young (<40y). The tangle of vessels does not contain any functioning brain. Arteries connect directly with veins - which dilate. Bleeds occur at a rate of 2% per annum, and approximately a  third are associated with death or disability. Rebleeds are 10% in the first year, then the rate falls off. There are a range of good treatment options for lower grade AVM, but some high grade AVM cannot be treated safely.

Treatment aims to completely obliterate the AVM - to prevent future haemorrhage. Timing and modality of treatment need to be thought about carefully. Modalities may be surgical resection (immediate cure with some risk), endovascular glue embolisation (most useful as an adjunct to surgery), or Gamma Knife stereotactic radiosurgery (GK-SRS) (which can be effective with no immediate risk, but there is a lag of a few years to obliteration, a small failure rate, and a low complication rate).

Cerebral aneurysms are areas of weakness on brain arteries. They can bleed causing either subarachnoid haemorrhage or intracerebral haemorrhage. 

Ruptured aneurysms need to be repaired as an emergency to prevent further bleeding. The UK aspirational standard is to undertake definitive repair of the ruptured aneurysm within 48h of bleeding. 

Unruptured aneurysms are commonly found on brain scans. Careful assessment by a specialist neurosurgeon is required to plan management.

Scoring systems may be helpful in formulating management plans.

PHASES

UIATS

Cavernous malformations (also known as cavernous, or cavernous angioma) are thin-walled low flow vascular malformations. They are commonly seen on brain MRI. They have a popcorn appearance. They are often incidental findings. Rates of haemorrhage are less than 1% per annum. They can cause local disturbance of brain function with or without haemorrhage, and can cause epileptic fits.

Very few need to be treated, and treatment by surgical removal (complete excision prevents future haemorrhage), or Gamma-knife stereotactic radiosurgery can be effective at preventing or lowering risk of future haemorrhage. 

The CARE trial is about to start recruiting patients- with randomisation between treatment and conservative management. Both GK and surgery are being compared with the "No treatment" cohorts.