Hypertensive cerebral hemorrhage, commonly known as cerebrovascular accident, cerebral hemorrhage, stroke, mahjong wind, wind paralysis, etc., is a fierce disease with a very high mortality rate, and even if it does not kill, most of them are disabled. Generally speaking, the higher the blood pressure of hypertensive patients, the higher the incidence of stroke. The age of onset is mostly 50-60 years old, but hypertensive patients aged 30-40 years old can also develop the disease. According to a survey in 6 cities in China, the prevalence of cerebral hemorrhage is 112/100,000, and the mortality rate of cerebral hemorrhage takes the first place in the whole cerebrovascular disease.
Common Causes
The common causes of cerebral hemorrhage are hypertension and atherosclerosis.
Diagnostic criteria of hypertension: In March 1993, WHO proposed new criteria for the diagnosis of hypertension: adult hypertension ≥ 18.67/12KPa [140/90mmHg), normal adult blood pressure: <18.67/12KPa.
High-risk groups.
①People with a history of hypertension in both parents or or one parent;
②Body mass index ≥25 or weight (kg) >1.1×(height (CM)-105) of overweight obese people, including children and adolescents;
③ salt intake ≥ 10g / day, the physiological requirement of sodium salt for healthy adults is 5g / day;
④Drink high alcohol ≥ 100g/day and drink alcohol ≥ 4 times/week;
⑤ High blood pressure values: SOP 17.33-18.53kPa and/or DBP 11.33-11.87kPa;
(6) Those who smoked ≥20 cigarettes/day for more than one year;
(⑦) Those who are frequently exposed to noise, high tension and emotional instability;
(8) Those who have taken oral contraceptives continuously for more than one year;
(9) Those who do not exercise much.
The real danger of hypertension is the damage to the heart, brain, kidneys and other important organs, resulting in stroke (stroke), myocardial infarction, kidney failure (serious will lead to uremia) and other serious consequences.
Blood vessels often harden in old age, and persistent hypertension is more likely to lead to cerebral arteriosclerosis and fatty glassy changes in the vessel walls, thus weakening the strength of the vessel walls. In addition, the structure of cerebral vascular wall is weak, with few myocytes in the middle layer of blood vessels, lack of outer elastic layer, and underdeveloped outer membrane of arteries, which can easily lead to limited dilation of small arterial walls in the brain and the formation of cornual microaneurysms. When the blood pressure rises suddenly due to emotional excitement or excessive force, it can cause the small blood vessels in the brain to rupture and bleed.
Susceptible site
Brain hemorrhage usually has 5
The most common site is the shell nucleus hemorrhage in the deep part of the cerebral hemisphere, accounting for about 60%. This is followed by thalamic hemorrhage, subcortical white matter hemorrhage, pontocerebellar hemorrhage and cerebellar hemorrhage, each accounting for about 10%. Once cerebral hemorrhage occurs, local brain tissue is not only destroyed, but also due to the occupancy of the hematoma and surrounding brain tissue edema, resulting in increased intracranial pressure, deepening, bilateral pupil dilatation and obvious disturbance of vital signs, and in severe cases, fatal brain herniation can occur. In case of thalamic or pontocerebral hemorrhage, even if the bleeding volume is small, it is often life-threatening.
Diagnostic criteria
The diagnosis of hypertensive cerebral hemorrhage can generally be made based on clinical manifestations. The age of onset is mostly above middle age, with a previous history of hypertension, and the onset is more frequent in the cold season. Patients may have triggers such as excessive exertion, anger, emotional excitement, etc., often with sudden onset, dizziness, headache, nausea, limb numbness, weakness and other symptoms, or even severe headache, vomiting, hemiparesis and impaired consciousness, then cerebral hemorrhage should be considered. To determine the site of bleeding and the size of hematoma, special examination is required. In the past, cerebral angiography was mostly used, but in recent years, the application of CT scan has made the diagnosis of cerebral hemorrhage more accurate, safe and easy, and CT examination can clearly show the site of hemorrhage, the size of hematoma, the direction of hemorrhage expansion and the extent of cerebral edema, which provides an important basis for the selection of treatment methods. A CT examination can be performed in just a few minutes, which is a major advance in the diagnosis of hypertensive cerebral hemorrhage. The newly used MRI can also help to make an accurate diagnosis of cerebral hemorrhage in a short time.
Treatment methods
The treatment of hypertensive cerebral hemorrhage mainly includes medical treatment and surgical treatment. These two treatments should be selected appropriately according to the condition.
Internal treatment includes bed rest and blood pressure control with antihypertensive drugs to maintain blood pressure slightly higher than the basal blood pressure. Intravenous mannitol is given to reduce cerebral edema and lower intracranial pressure. Maintain nutrition and water-electrolyte balance, and actively prevent and treat complications. Hypertensive cerebral hemorrhage mostly stops 20-30 minutes after bleeding, and the use of hemostatic drugs does not have definite efficacy.
Internal therapy is indicated for the following conditions.
(1) Those with small bleeding volume. It is generally considered that internal therapy can be performed for shell nucleus hemorrhage or subcortical hemorrhage less than 30 ml or hematoma diameter less than 3 cm.
(2) Those who have been conscious or only drowsy after hemorrhage.
(3) The patient is in a deep coma after the onset, or the disease has progressed to an advanced stage, and the coma is not suitable for surgical treatment.
(4) Patients who are greatly aged and have heart, lung and kidney disorders, or severe diabetes mellitus. The mortality rate of medical treatment is high, 50-90%.
Cushing first used surgery to treat hypertensive cerebral hemorrhage in 1903, which cooled down for a while because of the very poor results. For a long period of time in the past, medical treatment of cerebral hemorrhage was mostly advocated, and surgical treatment was rarely adopted. In recent years, due to the application of CT examination, the surgical cases of cerebral hemorrhage were reasonably selected, and microscopic techniques were applied to remove the hematoma and bipolar electrocoagulation to stop the hemorrhage intraoperatively, thus making the surgery more delicate and accurate and reducing the damage to a minimum. Early surgery, i.e., within 24 to 48 hours after the onset of the disease, is also adopted. Even ultra-early surgery, which is performed within 7 hours after cerebral hemorrhage, has been proposed. Since early removal of hematoma and reduction of intracranial pressure can not only achieve life-saving purpose, but also help to promote brain function recovery and reduce disability, some people summarize the results of surgical treatment of 929 cases of hypertensive cerebral hemorrhage reported in the literature in the past 5 years, the operative mortality rate was 2-28% and the functional recovery rate was 63-89%.
Surgical treatment criteria for hypertensive cerebral hemorrhage.
1, supratentorial (cerebral hemisphere) hematoma volume > 40 ml, with or without cerebellar herniation (cerebral herniation)
2. Subscallosal (cerebellar hemisphere) hematoma volume >15ml, with or without obstructive hydrocephalus
3, ventricular hemorrhage forming ventricular casts and obstructed cerebrospinal fluid circulation
Timing of surgical intervention.
1.After conservative medical treatment is ineffective and the condition is gradually aggravated, it should be strived to suffer irreversible damage to brain tissue-active treatment.
2.The amount of hematoma reaches the indication of surgery, and the patient does not develop cerebellar curtain incisional herniation despite coma-active treatment.
3.If the hematoma reaches the surgical indication and the herniation of the cerebellar curtain is present, the patient should be treated actively.
Choice of surgical methods.
Conventional flap craniotomy, small bone window craniotomy, minimally invasive or stereotactic aspiration and drainage.
Advantages of conventional flap craniotomy.
Able to completely remove the hematoma; adequate decompression; able to completely stop the hemorrhage under good direct vision; timely elimination of the compression effect of the hematoma on the surrounding brain tissue; abort the stimulation damage effect on the brain tissue after hematoma dissolution; removal of the bone flap can minimize the damage of postoperative cerebral edema.
Advantages of minimally invasive means.
Minimal trauma to normal brain tissue (minimally invasive), no need to make a big effort; short operation time, often only 0.5-1 hour; easy operation, only a special hematoma puncture needle with some necessary surgical equipment; high safety factor; little patient pain and few complications.
In recent years, some new treatment methods have been adopted in the treatment of cerebral hemorrhage. For example, cranial drilling is performed to inject urokinase into the hematoma cavity to promote the liquefaction of the clot, and then it is aspirated. This method is simple and easy to perform, and its efficacy is confirmed. In addition, cT-guided brain stereotactic removal of hematoma and CT localization and endoscopic removal of hematoma have also been developed. These treatment methods not only cause little damage, but also have good efficacy and are readily accepted by patients. With the emergence of new treatment methods, the treatment effect of hypertensive cerebral hemorrhage will continue to improve.