Hypertensive cerebral hemorrhage refers to non-traumatic bleeding in the brain parenchyma. It is the most serious type of acute cerebrovascular disease, and is one of the most lethal diseases among the middle-aged and elderly. Most of them are caused by the rupture of small cerebral artery lesions associated with hypertension when the blood pressure rises suddenly.
I. Etiology
There are many causes of cerebral hemorrhage, the most common cause is hypertensive atherosclerosis, followed by congenital cerebrovascular malformation or aneurysm, hematologic disease, traumatic brain injury, anticoagulation or thrombolytic therapy, amyloid angiopathy and other causes of cerebral hemorrhage. The classification according to etiology is as follows.
1.According to vascular pathology there are microaneurysm or microangioma, cerebral arteriovenous malformation (AVM), amyloid cerebral vasculopathy, cystic hemangioma, intracranial venous thrombosis, meningeal arteriovenous malformation, atopic arteritis, fungal arteritis, smoker’s disease and arterial anatomical variation, etc.
2. According to hemodynamics there are hypertension and migraine. Hematological factors are anticoagulation, antiplatelet or thrombolytic therapy, Haemophilus infection, leukemia, thrombotic thrombocytopenia, etc.
3.Other intracranial tumors, alcoholism and sympathetic excitatory drugs, etc.
4.Understood causes such as idiopathic cerebral hemorrhage.
II. Clinical manifestations
1.Hemorrhage in the nucleus accumbens and basal ganglia
Hemorrhage in the nucleus accumbens and basal ganglia is the most common site of hypertensive cerebral hemorrhage, mostly affecting the internal capsule. Patients often have head and eyes turned to the side of the hemorrhagic lesion, showing “focal gaze” and “triple hemianopia”, i.e. hemiparesis, hemianesthesia and hemianopsia. In the early stage, the muscle tone and tendon reflexes of the limb on the side of the hemorrhagic lesion decreased or disappeared, and then gradually became higher, the upper limb was flexed and inward, the lower limb was extended and straightened, the tendon reflexes became hyperactive, ankle clonus could occur, and the pathological reflexes were positive, which was typical of upper motor neuron hemiparesis. The hemorrhagic foci have hyperalgesia on the contralateral side of the hemiplegia, and there is no response when needling the limb or face or the response is slower than the other side. If the patient is clearly conscious and cooperates with the examination, the patient may also be found to have ipsilateral hemianopia contralateral to the hemorrhagic focus. If the hematoma breaks into the lateral ventricle, or even fills the whole lateral ventricle, it is called lateral ventricular cast, and its prognosis is poor.
2.Pontocerebral hemorrhage
Cerebral bridge hemorrhage often starts suddenly and enters deep coma within a few minutes, and the condition is critical. Cerebral bridge hemorrhage often starts from one side of the cerebral bridge, and then spreads to both sides quickly, resulting in bilateral limb paralysis. Most of them are flaccid, a few are spastic or decorticate tonic, and bilateral pathological reflexes are positive. The characteristic sign is extreme narrowing of the pupils on both sides in a “pinpoint” fashion. Some patients may develop central hyperthermia, irregular breathing and dyspnea, and often die within 1 to 2 days.
3.Cerebellar hemorrhage
Patients with mild cerebellar hemorrhage start with clear consciousness and often complain of severe headache and vertigo in the posterior occipital region, frequent vomiting, slurred pronunciation, and nystagmus. The limbs are often not paralyzed, but ataxia occurs in the limb on the side of the lesion. When the hematoma gradually enlarges and breaks into the fourth ventricle, it may cause acute hydrocephalus. In severe cases, herniation of the foramen magnum occurs, and the patient suddenly falls into coma, has irregular breathing or even stops, and eventually dies due to respiratory and circulatory failure.
III. Examination
When bleeding enters the subarachnoid space and secondary subarachnoid hemorrhage occurs, lumbar puncture may reveal bloody cerebrospinal fluid.
CT scan of the head is the preferred examination, which can quickly clarify the site, scope and volume of intracerebral hemorrhage, as well as whether the hematoma breaks into the ventricle and whether it is accompanied by subarachnoid hemorrhage, etc. It can also identify cerebral edema and cerebral infarction, and the occupying effect of the hematoma can be inferred by the displacement of the lateral ventricle by pressure, the displacement of the falx and the loss of the basal pool, which can help in the selection of treatment plan and prognosis, and also according to the hematoma It can also be used to identify other etiologies, such as vascular malformations, aneurysms, and tumors, based on the location of the hematoma and the enhanced CT presentation.
When the cause of cerebral hemorrhage is suspected to be other than hypertension, MRI examination is valuable for differential diagnosis of cerebrovascular malformations, tumors, and intracranial giant aneurysms, etc. However, MRI examination is time-consuming, and in acute cases with severe disease, the patient’s vital signs and airway must be monitored during the examination to prevent accidents. In addition, the MRI manifestations of hematomas at different times are complicated, sometimes making the diagnosis difficult.
Cerebral angiography can clearly diagnose aneurysm or vascular malformation, but when cerebral angiography is negative, especially in large intracerebral hematoma, it should be considered that the ruptured aneurysm or vascular malformation is temporarily compressed and obstructed, and the angiography can also be false negative in small vascular malformation.
IV. Diagnosis
According to the history and clinical characteristics of hypertension, it is generally not difficult to make a clinical diagnosis. Brain CT and magnetic resonance scan are the most helpful for diagnosis, not only to confirm the diagnosis at an early stage, but also to accurately understand the site of hemorrhage, the amount of hemorrhage, the extent of the wave, the presence of ventricular penetration and the condition of the brain tissue around the hematoma. The onset of the disease is usually in middle age or older, with a previous history of hypertension and more frequent in the cold season. Brain hemorrhage should be considered when there is a sudden onset of severe headache, vomiting, hemiparesis and impaired consciousness. 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.
V. Differential diagnosis
1. Cerebral infarction
Cerebral infarction mostly develops at rest and may have a history of transient ischemic attack, mostly without consciousness impairment, headache, vomiting or meningeal irritation signs. Small amount of hemorrhage is similar to cerebral infarction, and severe cerebral infarction can appear with obvious cranial pressure increase or even cerebral herniation, CT scan has high density shadow in low density, and lumbar puncture is helpful for small amount of hemorrhage.
2.Hypertensive encephalopathy
Hypertensive encephalopathy is a transient headache, vomiting, convulsions or impaired consciousness, without clear neurological focal signs, with increased blood pressure and fundus changes as the main manifestations, clear cerebrospinal fluid and increased pressure.
3.Other
The disease also needs to be distinguished from subarachnoid hemorrhage, diabetic coma, hepatic coma, uremia, acute alcohol intoxication, hypoglycemia, drug intoxication, CO intoxication, etc.
VI. Treatment
Surgical treatment of hypertensive cerebral hemorrhage should be valuable only when non-surgical treatment has failed and the hemorrhage has not yet caused primary or secondary fatal damage. The aim of surgical treatment is to eliminate the hematoma, lower the intracranial pressure, relieve the occurrence and development of cerebral herniation, improve cerebral circulation, and promote the early recovery of compressed brain tissue. In conclusion, the treatment of hypertensive cerebral hemorrhage is selective. If the hemorrhage is small, it can be treated by internal medicine, and if the hematoma is large, such as the volume of hematoma in the external or internal capsule area reaches 20 ml or more, timely craniotomy or brain stereotactic surgery to remove the hematoma often helps to release the brain from pressure and promote recovery. Stereotactic hematoma aspiration is precise in localization and has little surgical damage, which is especially suitable for hematoma removal in deep brain or important functional areas. Surgical treatment is sometimes difficult to achieve in patients with acute onset, deterioration within a short period of time, coma, and deactivation of the brain.
Non-surgical treatment includes absolute bed rest, sedation and blood pressure stabilization, application of dehydrating drugs, hemostatic drugs, maintenance of water and electrolyte balance, supportive therapy, and attention to keeping the respiratory tract unobstructed. Comatose patients should be meticulously cared for to prevent complications such as pneumonia and gastric bleeding in a timely manner, and still require medical aspects of treatment after surgery. Hypertensive cerebral hemorrhage mostly stops 20-30 minutes after bleeding, and the use of hemostatic drugs does not have definite efficacy.
Internal medicine treatment is indicated for the following conditions.
1. Those with small bleeding volume. It is generally considered that shell nucleus hemorrhage or subcortical hemorrhage less than 30 ml or hematoma diameter below 3 cm can be treated internally.
2.People who have been conscious or only drowsy after hemorrhage.
3, the onset of the disease is into a deep coma, or the disease has developed to an advanced stage, coma is not suitable for surgical treatment.
4.Patients who are greatly aged and have heart, lung and kidney disorders, or have severe diabetes mellitus. The mortality rate of medical treatment is high.
VII. Prevention
Patients with hypertension should control their blood pressure under the guidance of a physician and avoid factors that may induce an increase in blood pressure such as violent changes, full meals, strenuous activities, forceful defecation, and sexual intercourse. If severe posterior headache or collar pain, motor sensory disturbance, vertigo or syncope, rhinorrhea, blurred vision, etc. occur, they may be precursors of cerebral hemorrhage. The dosage and usage of the above drugs must follow medical advice.
Most of them are caused by the rupture of small cerebral artery lesions associated with hypertensive disease when the blood pressure rises suddenly, called hypertensive cerebral hemorrhage. Some patients may experience inability to move one or both hands and feet, weakness, or temporary inability to speak, which may have certain effects in later life. You should have a correct understanding of your disease, as long as you control it early with medication, carry out various functional exercises and language rehabilitation training (such as counting, looking at pictures and talking, etc.), and be persistent, this will have a positive effect on the rehabilitation of paralyzed hands and feet and language function.
The diet should be high in protein, high in vitamins, low in fat and easy to digest nutrient-rich foods, such as fish, soy products, grains, soybeans, etc. Avoid spicy stimulating and greasy foods (such as strong tea, coffee, fried foods), more vegetables and fruits, and keep bowel movements smooth. If there is facial paralysis, semi-liquid food, such as milk paste or porridge, should be fed to the healthy side (where there is no facial paralysis), and the feeding speed should be slow to avoid choking and coughing, which may cause choking. If the patient is critically ill and has difficulty in swallowing, the doctor will insert a gastric tube and give nasal feeding to ensure nutrition supply.
Because the patient’s limbs are affected by the disease, the patient’s sensation of hot and cold stimuli is dulled, so the family is reminded not to use hot water bags and other warming devices to help warm up when it is cold. Otherwise, it may cause serious consequences such as burns. Patients with unfavorable limb movement and urinary and fecal incontinence should pay attention to skin protection, clean the perineal skin after each bowel movement, keep it dry, apply talcum powder appropriately, and turn and pat the patient’s back every two hours to avoid long-term pressure and necrosis on the skin of paralyzed limbs and the occurrence of bedsores. Within 1 to 2 weeks after the onset of the disease, when the condition is basically stable, functional exercise of the affected limb can be carried out early, ranging from 10 to 20 times three times a day, with massage and passive activities to prevent joint adhesions and muscle atrophy. The number of exercises can be increased later to help early recovery.