hypertensive cerebral hemorrhage



Overview

Definition

Hypertensive cerebral hemorrhage is defined as a sudden onset of parenchymal hemorrhage in the basal nuclei, ventricles, cerebellum, and brainstem in a person with a clear history of hypertension. Secondary cerebral hemorrhage caused by trauma, vascular structural anomalies, coagulation disorders, hematologic disorders, systemic disorders, and neoplastic disorders is excluded.

Hypertensive cerebral hemorrhage is the most common type of cerebral hemorrhage and one of the serious complications of hypertension.

Morbidity

In Europe and the United States, the prevalence of this disease accounts for 9% to 28% of strokes; in China, the prevalence of this disease accounts for 19% to 48% of strokes.

It is more common in middle-aged and elderly people, and is slightly more common in men than in women.

Causes

Causes

Due to long-term high blood pressure, vitreous degeneration and fibrinoid necrosis occur in small arteries of the brain, or tiny aneurysms are formed.

When the blood pressure rises suddenly, the blood vessels are prone to rupture and hemorrhage, leading to cerebral hemorrhage.

Predisposing factors

The following factors can trigger the above causes and cause an attack or aggravation of the disease.

Emotional stress.

Excessive mental or physical activity.

Heavy alcohol consumption.

Cold weather.

Symptoms

Sudden onset of symptoms occurs during emotional stress or activity, and the condition often peaks within a few minutes to a few hours after onset. A small number of cases may also occur in a quiet state. Specific clinical manifestations are related to the location and amount of bleeding.

Prodromal symptoms

Prodromal symptoms are usually not obvious.

A few patients have prodromal symptoms such as dizziness, headache, nosebleed and conjunctival hemorrhage, and obviously elevated blood pressure.

Main Symptoms

Bleeding in the basal nuclear region

Bleeding in the nucleus accumbens

The most common hemorrhage is hemiparesis on the opposite side of the hemorrhagic focus, hemiplegia, hemianopic sensory loss (e.g., unable to feel pain from pinprick, no sensation from touching the skin, and unable to distinguish between hot and cold), and binocular visual field loss in the same direction.

There may also be an inability to look at the hemorrhage side with both eyeballs, but rather stare at the side opposite the hemorrhage.

This is sometimes accompanied by difficulties in verbal communication.

Thalamic hemorrhage

Symptoms are similar to thalamic hemorrhage.

Patients may have characteristic ocular manifestations, such as staring at the tip of the nose or the inability to gaze upward with both eyes.

Speech disorders, psychiatric disorders, cognitive disorders and personality changes may also be present.

Caudate nuclear head hemorrhage

Patients often present with headache, vomiting, stiff neck with limited movement, and psychiatric symptoms.

Brain stem hemorrhage

Brain bridge hemorrhage

Large amount of hemorrhage can quickly lead to coma, bilateral pupil narrowing like pinpoints, vomiting coffee-like gastric contents, high fever, irregular breathing, floating eyes, quadriplegia, and de-cerebralization (stiff limbs, head tilted backward, and the body tilted like a bow) and other symptoms.

Patients with small amount of hemorrhage may have no consciousness disorder, and they mostly show hemorrhagic facial paralysis (lightening or disappearance of headlift and decussation, drooping of mouth corner, incomplete eyelid closure), weakness of contralateral limbs, and inability to rotate both eyes downward, upward, or to one side at the same time.

Middle brain hemorrhage

In mild cases, headache, vomiting, diplopia, ptosis, nystagmus, unsteady walking, slurred speech, difficulty in swallowing, choking on drinking water.

In severe cases, the patient may suffer from deep coma, quadriplegia and rapid death.

Cerebellar hemorrhage

If the hemorrhage is small, it mainly shows symptoms of cerebellar damage, such as clumsy and uncoordinated movement on the affected side, nystagmus and so on, mostly without paralysis.

If the hemorrhage volume is larger, the condition will progress rapidly, and coma and signs of brainstem compression will appear at the onset of the disease or within 12-24 hours after the disease, such as bilateral pupil narrowing to pinpoint, irregular respiration, etc. In severe cases, the patient may suddenly fall into a coma.

In severe cases, the patient may suddenly fall into a coma and die rapidly within a few hours.

Ventricular hemorrhage

Patients often have headache, vomiting, pinpoint pupils, convulsions or paralysis of limbs, high fever, and irregular breathing.

Complications

Stress ulcers

The body may be in a state of stress after the onset of the disease, which affects the digestive tract and the central nervous system and triggers stress ulcers.

It may be manifested as vomiting blood, black stools, etc.

Pressure Sore

These sores occur in patients who are bedridden for a long period of time.

Redness, swelling, heat, pain or numbness appear on the skin at the site of long-term pressure, and erythema that does not fade after pressing.

In severe cases, blisters, increased pus secretion and pain may appear locally.

Deep Vein Thrombosis of Lower Extremity

Long-term bed-ridden people with poor blood flow in the lower limbs, as well as people with hypercoagulable blood are prone to this condition.

It is characterized by swelling, pain, tenderness and fever in the affected limbs.

Pulmonary Embolism

It occurs in people who have been bedridden for a long time and whose blood is in a high viscous state.

Common symptoms include dyspnea and shortness of breath, chest pain, fainting, restlessness, a sense of dying, hemoptysis, and fever.

Consultation

Department of Medicine

Neurology

For symptoms such as facial numbness, vomiting, dizziness, weakness on one side of the body, unsteady gait, unclear speech, etc., it is recommended to consult a doctor promptly.

Emergency Department

In case of sudden onset of severe headache, unconsciousness or other emergencies, it is recommended to go to the Emergency Department as soon as possible or call the 120 emergency number.

Preparation for medical treatment

Preparing for medical treatment: registration, preparation of documents, common problems

Tips for medical treatment

If you have the habit of monitoring and recording your blood pressure every day, you can provide your blood pressure record to the doctor for more reference.

Special tips: Family members are recommended to accompany the doctor, avoid driving or riding to the doctor.

Preparation Checklist

Symptom list

Pay special attention to the time of onset of symptoms, special manifestations, etc.

Are there any significant changes in limb movement, sensation, speech function, vision, etc.?

Are there any signs of dizziness, headache, difficulty in swallowing, etc.?

How long have these symptoms been present? Have they worsened or subsided?

Medical History Checklist

Is there a history of hypertension? If so, how is the blood pressure controlled?

Was there any emotional excitement, excessive mental or physical activity prior to the onset of symptoms?

Checklist

Test results from the last six months, which can be brought with you to the doctor’s office

CT head, magnetic resonance imaging (MRI) head

CT angiography, MRI angiography

Medication list

Medication use in the last 3 months, if available in boxes or packages, can be brought to the doctor’s office

Medications to adjust blood pressure: furosemide, metoprolol, nifedipine, etc.

Diagnosis

Diagnostic basis

Medical history

History of hypertension.

Emotional excitement, excessive mental or physical activity before the onset of the disease.

Clinical manifestations

The onset of the disease is mostly sudden, mainly characterized by headache, vomiting, limb weakness, difficulty in verbal communication, facial paralysis or coma.

Blood pressure is markedly elevated at the onset.

Laboratory tests

Including blood routine, urine routine, liver and kidney function, coagulation function and other tests.

The test results vary according to the condition and are mainly used to understand the patient’s general status.

Imaging examination

Cranial CT

It is the first choice for diagnosing cerebral hemorrhage, and can clearly show the location of bleeding, the amount of bleeding, and the shape of hematoma.

The foci are mostly round or ovoid uniform high-density areas with clear boundaries.

When there is a large amount of blood accumulation in the ventricles, it is mostly in the form of high-density casts and the ventricles are enlarged.

Cranial MRI

Diagnosis of acute cerebral hemorrhage is not as good as that of CT, but it helps to accurately diagnose isodense hematoma which is difficult to be determined by CT and helps to differentiate intracranial diseases.

At the onset of <24 hours, it is long T1 and long T2 signal; at the onset of 2-7 days, it is equal T1 and short T2 signal.

Other imaging tests

CT angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), which can show the lumen and wall of blood vessels, can be important supplementary examinations.

Differential Diagnosis

Cerebral infarction

Similarity: hemiparesis, speech disorder, consciousness disorder, etc. can occur in both cases.

Differences: Cerebral infarction often has risk factors such as atherosclerosis, and may have a history of transient ischemic attack (transient symptoms such as darkness, dizziness, hemiparesis, etc., which may recur repeatedly), while headache, nausea, and vomiting are rare. A CT scan of the head is helpful in differentiation.

Subarachnoid hemorrhage

Similarities: headache, nausea, vomiting, impaired consciousness.

Differences: Subarachnoid hemorrhage is characterized by rapid progression, severe headache, and absence of hemiparesis and hemianopsia. Cranial CT, MRI and cerebrospinal fluid examination can help to differentiate.

Traumatic intracranial hematoma

Similarity: headache, nausea, vomiting and other symptoms.

Differences: Traumatic intracranial hematoma often has a history of head trauma, and cranial CT examination is helpful for differentiation.

Treatment

Aim of treatment: to save the patient’s life, reduce the mortality rate and disability rate, and minimize the recurrence of the disease.

Treatment principles: quiet bed, dehydration, lowering cranial pressure, adjusting blood pressure, preventing further bleeding, strengthening nursing care, preventing and controlling complications.

General treatment

Bed rest

General patients should have bed rest for 2 to 4 weeks.

Avoid emotional excitement and strenuous activities.

Keep the airway open

Comatose patients should tilt their head to one side to facilitate the flow of oral secretions and vomit.

For critically ill patients or those with airway involvement, give airway support and assisted ventilation if necessary.

Nutritional support

For those with consciousness disorder and gastrointestinal bleeding, fasting for 24 to 48 hours is recommended, and stomach contents should be emptied if necessary.

Patients who are comatose or have difficulty in swallowing can be fed through nasal feeding tube if they cannot resume voluntary feeding in a short period of time.

Medication

Drugs for lowering intracranial pressure

Hypertonic dehydrating drugs are mainly used to reduce cerebral edema, lower intracranial pressure, and prevent cerebral hernia formation.

Mannitol is the most important drug for lowering intracranial pressure, and furosemide can be injected intravenously or intramuscularly at the same time, and the two can be used alternately.

Glycerol fructose has a mild dehydrating effect without rebound phenomenon and is suitable for patients with renal insufficiency.

Intravenous injection of human albumin can increase plasma colloid osmotic pressure and reduce cerebral edema, but it is expensive and its application is limited.

The patient’s urine output, water and electrolytes should be monitored during the medication.

Adjustment of blood pressure drugs

Reduce blood pressure to achieve the purpose of reducing the volume of hematoma and improve the prognosis.

Intravenous antihypertensive drugs such as nicardipine and nitroglycerin are commonly used.

Commonly used oral antihypertensive drugs, including diuretics (such as furosemide, spironolactone), β-blockers (such as metoprolol, atenolol), calcium channel blockers (such as amlodipine, nifedipine), angiotensin-converting enzyme-inhibiting drugs (such as captopril, enalapril), and angiotensin II receptor blocking drugs (such as chloretin, valsartan).

The patient’s blood pressure should not be lowered too quickly, and monitoring needs to be strengthened to prevent cerebral hypoperfusion caused by too rapid a fall in blood pressure.

Hemostatic drugs

Help to limit the expansion of hematoma, but cannot improve the survival rate and neurological prognosis of patients.

Tranexamic acid is mostly applied.

Excessive or prolonged use should be avoided to avoid increasing the risk of cerebral ischemic disease.

Surgery

Principles of Surgery

Doctors will decide on the surgical plan according to the location and amount of bleeding, as well as the patient’s age, state of consciousness, and general condition.

It is generally considered that surgery should be performed at an early stage (within 6 to 24 hours after the onset of the disease).

Indications

Bleeding of moderate amount or more in the basal nucleus (≥30ml in the chiasmatic nucleus, ≥15ml in the thalamus).

Cerebellar hemorrhage ≥10ml or diameter ≥3cm, or combined with obvious hydrocephalus.

Severe ventricular hemorrhage (ventricular casts).

Combined cerebrovascular malformation, aneurysm and other vascular lesions.

Surgical approach

Mainly include debridement decompression, small bone window craniotomy hematoma removal, drilling hematoma aspiration and ventricular puncture drainage.

Precautions

Drainage tubes will be placed and drainage bottles will be installed during the surgery. Avoid dislodging or damaging the drainage tubes and bottles after the surgery.

Observe the amount of fluid in the drainage bottle and inform the doctor or nurse as required.

Inform the doctor promptly if there is redness, swelling, bleeding, severe pain or dislodging of the drainage tube at the location of the drainage port.

Rehabilitation

Generally, after the patient’s vital signs are stabilized, rehabilitation treatment should be started as soon as possible. 3 months after the onset of the disease is the “golden” rehabilitation period, and 4~6 months is the “effective” rehabilitation period.

Under the guidance of the doctor, the patient can be trained to turn over to the healthy side and the affected side, bridge exercise and other limb function training, as well as speech and sensory function training.

Prognosis

Cure

The overall prognosis is poor, and the prognosis is related to the amount of bleeding, the site of bleeding and the presence of complications.

Patients with mild cases can improve significantly after treatment and even resume work; those with massive hemorrhage in the brainstem, thalamus and ventricles have a poorer prognosis.

The disease has a high risk of recurrence, and the risk of recurrence is higher in people of advanced age, hypertension and deep hemorrhage.

Hazards

This disease has high morbidity, mortality and disability, which brings heavy life and economic burden to the society, family and patients.

Some patients often suffer from pressure ulcers, lower extremity venous thrombosis, pulmonary embolism and other complications due to prolonged bed rest, which seriously affects the quality of life and physical health.

Daily Management

Daily Management

Dietary management

For those who have difficulty in eating, nasal feeding is required, and intravenous supplementation of nutrient solution is needed when necessary.

Those who can eat normally should pay attention to a light diet, avoid spicy, fried, animal offal and other foods. Food form should be soft and easy to digest.

Alcohol consumption is prohibited.

Exercise management

Patients should actively carry out rehabilitation therapy under the guidance of doctors, and need to be accompanied by family members during training to prevent accidents such as falling and falling out of bed.

Ensure the safety of the exercise environment, remove sharp objects around the training, do not allow debris to obstruct the route.

Choose the right time for training. It is not advisable to train on an empty stomach or on a full stomach after a meal.

If you feel unwell during training, stop training immediately and relax at the right time.

Ensure that the training intensity is appropriate, and gradually increase the training intensity.

Life Management

Pay attention to rest and avoid exertion.

Wear soft, loose, easy to put on and take off cotton clothes.

If there is hemiplegia, lower limb weakness, etc., you should choose crutches, walking aids, etc. to carry out activities, or be supported by family members or pushed by wheelchair.

Quit smoking and avoid passive smoking.

For those who use medication, take medication on time as prescribed by the doctor.

For those who are bedridden for a long time, they should turn over diligently and avoid pushing, dragging, pulling and tugging when turning over.

For patients with slurred speech, communication tools such as paper, pens and drawing boards can be provided to help patients express their needs.

Encourage patients to do what they can and try to live on their own.

Psychological support

Pay attention to the patient’s mental health, release pressure in time, and avoid bad emotions such as anxiety and depression.

Family members should pay attention to the patient’s mental state, listen patiently, and communicate and interact with the patient more often.

Disease monitoring

If the patient’s symptoms worsen during treatment, or new symptoms appear, timely consultation is required.

Observe the patient’s language expression and physical activities for any changes.

Patients with hypertension are advised to monitor and record their blood pressure every day.

Follow-up

Regular checkups will help you understand how your disease is recovering, help your doctor guide your rehabilitation treatment, and help you detect recurrence in time.

Regular checkups as recommended by your doctor will usually include blood pressure, head CT, MRI, and so on.

Prevention

Limit salt intake (less than 5 grams per day is recommended) and reduce dietary fat content.

Reduce body weight and take appropriate physical exercise.

Stop smoking and reduce alcohol consumption.

Add clothing when going out in cold weather.

Stay in a good mood and avoid major mood swings.