Bleeding in the brain parenchyma due to hypertension is called hypertensive cerebral hemorrhage.
1. There is a history of hypertension, and it is common in middle-aged and elderly people, and it mostly starts suddenly during emotional excitement or physical activity.
2. Sudden headache is often the first symptom, followed by vomiting, convulsions, and impaired consciousness. The severity of the disease varies, with mild cases similar to cerebral infarction and severe cases with significant brain symptoms. The severity depends on the primary site of hemorrhage, the speed of hemorrhage, the amount of hemorrhage, the direction of expansion of the hematoma and the extent of its spread, as well as secondary pathological changes such as cerebral edema and cerebral ischemia.
Examination
1. Lumbar puncture: cerebrospinal fluid pressure is increased and is mostly bloody. If CT examination is available, lumbar puncture may not be performed to avoid aggravation of the condition and even induce brain herniation formation.
2.CT examination: High-density shadow is seen in the brain parenchyma to determine the site of hemorrhage, the amount of hemorrhage and the direction of expansion.
3.Cerebral angiography: It shows the signs of occupying lesions and helps to identify cerebral hemorrhage caused by other cerebrovascular diseases.
4.Cranial MRI: After the condition is stable, cranial MRI examination is performed, which helps to evaluate the prognosis of the patient.
Diagnosis
1.Make the diagnosis of hypertensive cerebral hemorrhage based on medical history, physical examination and auxiliary examination.
2.Make the diagnosis or estimate the bleeding site, bleeding speed, bleeding volume, direction of bleeding extension, hematoma wave extent, and secondary pathological changes such as cerebral edema and cerebral ischemia.
3.Differentiate from other non-hypertensive cerebral hemorrhage: such as cerebral hemorrhage caused by cerebrovascular malformation, cerebral aneurysm, cerebral amyloid angiopathy, hematologic disease, cerebral arteritis, oral anticoagulants, etc.
The acute phase is mainly to prevent further bleeding, reduce intracranial pressure, control cerebral edema, maintain vital functions and prevent and treat complications.
1. Selection of surgery.
(1) Bleeding site: Surgery should be given priority to superficial bleeding, such as subcortical, nucleus accumbens and cerebellar bleeding. Those with bleeding located deep in the internal capsule, thalamus and brainstem should not be operated.
(2) Bleeding volume: usually the bleeding volume of cerebral hemisphere is more than 30ml and cerebellar bleeding is more than 10ml, then surgery can be considered according to the condition.
(3) Evolution of the condition: If the condition progresses rapidly after hemorrhage and falls into deep coma, dilated pupils, irregular blood pressure, respiration and pulse within a short period of time, surgery should not be considered.
(4) Impairment of consciousness: those who are conscious mostly do not need surgery; those who have mild impairment of consciousness after the onset and slowly deepen thereafter, as well as those who are moderately impaired in consciousness when they come to the hospital, should actively undergo surgery.
(5) Other factors: age should not be considered as a factor for surgery, high blood pressure ≥200/120 mmHg after onset, fundus bleeding, and patients with serious heart, lung, liver and kidney diseases before surgery are mostly unsuitable for surgery.
2. Selection of surgery timing.
For patients suitable for surgery, early (1 to 3 days after bleeding) or ultra-early (within 7 hours after bleeding) surgery can be chosen to reduce the compression of the hematoma on the brain tissue as early as possible to avoid further secondary damage. For those with slow development of hematoma and stable condition, surgery can be performed at an elective stage.
3.Surgical methods.
Including craniotomy to remove the hematoma and puncture to aspirate the hematoma. The former is mostly used for patients with deep bleeding sites, large bleeding volume, severe midline shift, serious preoperative disease, and existing brain herniation formation, but for a short period of time; this method is also advocated for cerebellar hemorrhage. The latter can be applied to hemorrhage in various parts, especially deep hemorrhage, such as thalamic hemorrhage, brain parenchymal hemorrhage with ventricular hemorrhage.
1.Cure: symptoms basically disappear, muscle strength of paralyzed limbs reaches grade 4, language is restored, and life is basically self-care.
2.Improved: symptoms improved, muscle strength of paralyzed limbs improved by 1~2 levels, and life was partially self-care.
3.Unhealed: symptoms slightly improved, muscle strength of paralyzed limb improved less than 1 level, language not restored, life cannot be self-care.
If the treatment reaches the standard of improvement or above, or if the effect is still not obvious after more than 2 months of treatment, a treatment plan can be made and the patient can be transferred to a rehabilitation hospital for further treatment.