I: Diagnosis
①Sudden onset often occurs during physical activity or emotional excitement.
②The attack is often accompanied by recurrent vomiting, headache and elevated blood pressure.
③The disease progresses rapidly, often with impaired consciousness, hemiparesis and other focal neurological symptoms.
④Most often have a history of hypertension.
⑤Cranial CT examination can provide direct evidence of cerebral hemorrhage.
II: Differential diagnosis
①It should be differentiated from cerebral infarction when CT examination is not available.
②For those with sudden onset, rapid coma and non-obvious focal signs, attention should be paid to differentiate from systemic poisoning (alcohol, drugs, carbon monoxide) and metabolic diseases (diabetes, hypoglycemia, hepatic coma, uremia) that cause coma, and medical history and relevant laboratory tests can provide diagnostic clues without hemorrhagic changes on cranial CT.
(iii) Traumatic intracranial hematoma mostly has a history of trauma, and hematoma can be detected by cranial CT.
④If the hemorrhage is located in the shell nucleus, pallidum, thalamus, internal capsule, deep white matter around the ventricle, cerebral bridge, cerebellum, if there is a history of hypertension before the disease, basically the diagnosis of hypertensive cerebral hemorrhage can be confirmed; if there is no hypertension and other causes of lobar hemorrhage in the elderly, it is mostly due to amyloid cerebral vasculopathy; hemorrhage caused by hematological diseases and anticoagulation and thrombolytic therapy often has a corresponding medical history or treatment history; tumor, aneurysm, arteriovenous malformation In the case of tumors, aneurysms, arteriovenous malformations, etc., there are often corresponding findings in cranial CT, MRI, MRA and DSA examinations, and tumor strokes often show acute exacerbation in the course of chronic disease.
III: Treatment: Take active and reasonable treatment to save the patient’s life, reduce the degree of neurological disability and lower the recurrence rate.
1.Medical treatment
(1) Quietness should be maintained, bed rest, and visitation should be reduced. Closely observe body temperature, pulse, whistle and blood pressure and other vital signs, pay attention to pupil and consciousness changes. Keep the whistle tract unobstructed, clear the whistle tract secretions in a timely manner, and administer oxygen if necessary to maintain the arterial oxygen saturation above 90%. Enhance care and maintain the functional position of the limbs. With impaired consciousness and gastrointestinal bleeding it is advisable to fast for 24-48 hours, and then place a gastric tube as appropriate.
(2) Water-electrolyte balance and nutrition: the daily fluid intake after the disease can be calculated according to the amount of urine ten 500m1, such as those with high fever, excessive sweating, vomiting or diarrhea, the amount of fluid intake can be increased appropriately. Maintain central venous pressure at 5~12mmHg or pulmonary wedge pressure at 10~14mmHg level. Pay attention to prevent hyponatremia, which may aggravate cerebral edema. Replenish sodium 50-70mmol/L, potassium 40-50mmol/L and sugar 13.5-18g daily.
(3) Control cerebral edema and reduce intracranial pressure: cerebral edema reaches its peak in about 48h after cerebral hemorrhage and gradually decreases after 3-5d maintenance, which can last 2-3 weeks or longer. Cerebral edema can increase intracranial pressure and cause brain herniation, which is the main factor affecting the mortality and functional recovery of cerebral hemorrhage. Active control of cerebral edema and reduction of intracranial pressure is an important part of the acute treatment of cerebral hemorrhage; ICP monitoring is feasible when necessary and available.
Available options are.
① Mannitol: it can make plasma osmolality rise significantly in a short time, forming an osmotic pressure difference between blood and brain tissue; when mannitol is excreted from the kidneys, it can take away a large amount of water, about 8g of mannitol can take out 100ml of water; ICP starts to fall after 20-30 minutes of medication, and can be maintained for 4-6 hours; usually with 20% Mannitol 125-250m1 every 6-8h for 7-10d; if there are signs of cerebral herniation formation, rapid pressure can be pushed through the vein or carotid artery, but symptom relief is temporary and can only provide time for preoperative preparation; coronary artery disease, myocardial infarction, heart failure and renal insufficiency should be used with caution.
(ii) Diuretics: tachyphylaxis is more commonly used, often combined with mannitol to enhance the effect of dehydration, 40 mg each time, 2-4 times daily, intravenously.
③glycerol: should be used during the improvement period of mild symptoms or severe disease, 10% compound glycerol solution 500m1, once a day, intravenous drip, 3-6 hours to finish; dehydration, lowering cranial pressure effect is slower than mannitol, hemolysis is easy to occur when the dosage is too large or infusion is too fast;
④10% serum albumin: 50-100m1, once daily, intravenous drip, more suitable for patients with hypoproteinemia, can improve the colloid osmotic pressure, the effect is more lasting.
⑤ Dexamethasone: can reduce capillary permeability and maintain the blood-brain barrier function; it shows anti-cerebral edema effect only 12-36 hours after administration; it is not advocated for routine use because it is easy to complicate infection or promote stress ulcers in the upper gastrointestinal tract and affect the control of blood pressure and blood glucose; it can be applied for a short period of time early in critical condition, 10- 20mg/d, intravenous drip.
(4) Control of hypertension: the increase of blood pressure after cerebral hemorrhage is a cerebrovascular auto-regulatory response to maintain relatively stable cerebral blood flow (CBF) in the case of increased ICP, when ICP decreases blood pressure will also fall, so usually no antihypertensive drugs, especially strong antihypertensive drugs such as injectable reserpine; the optimal blood pressure level should be determined according to the patient’s age, the presence of hypertension before the disease, and the blood pressure after the disease. Systolic blood pressure of 180-230 mmHg or diastolic blood pressure of 105-140 mmHg should be treated with oral antihypertensive drugs such as captopril and betalactam; systolic blood pressure of 180 mmHg or less or diastolic blood pressure of 105 mmHg or less can be observed without antihypertensive drugs. If the increase in ICP is not obvious after the acute phase but the blood pressure continues to rise, systematic anti-hypertensive treatment should be carried out to control the blood pressure at a more desirable level. A sudden drop in blood pressure during the acute phase indicates a critical condition, and dopamine and alamin should be given promptly.
(5) Prevention and treatment of complications.
①Infection: early onset of milder patients with no evidence of infection, usually do not use antibiotics; combined with impaired consciousness of elderly patients prone to complications of pulmonary infection, or due to urinary retention or catheterization, etc. prone to combined urinary tract infection, can be given prophylactic antibiotic therapy, can be based on experience or sputum culture, urine culture and drug sensitivity test results of the choice of antibiotics; at the same time to keep the airway unobstructed, strengthen oral and airway care; sputum more If the sputum is not easy to cough up, tracheotomy can be performed in a timely manner, and bladder flushing should be performed regularly when the urinary catheter is left in place for urinary retention.
②Stress ulcers: can cause gastrointestinal bleeding. Prevention can be H2 receptor blockers, such as mecamiprid 0.2-0.4g/d, intravenous; ranitidine 150mg orally, 1-2 times a day; loxacre 20-40mg orally or intravenously daily; omeprazole 200mg orally, 3 times a day; and aluminum hydroxide gel 40 60m1 orally, 4 times daily; once bleeding should be treated according to the routine of upper gastrointestinal bleeding, hemostatic drugs can be applied, such as norepinephrine 4-8mg with cold saline 80-100m1 orally, 4-6 times/d; Yunnan Baiyao 0.5g orally, 4 times daily; if conservative internal medicine treatment is ineffective, hemostasis can be stopped under direct endoscopy; vomiting of blood should be prevented when it causes asphyxia, while fluid or blood should be rehydrated to maintain blood volume.
③Anti-diuretic hormone secretion abnormal syndrome: also known as dilutional hyponatremia, can occur in about 10% of ICH patients, because of increased sodium excretion via urine, blood sodium decreases and aggravates cerebral edema, water intake should be limited to 800~1000ml/d and sodium supplementation 9-12g/d; hyponatremia should be corrected slowly, otherwise it can lead to central pontine myelinolysis;
④Epileptic seizures: mainly generalized seizures, frequent seizures can be controlled by intravenous slow injection of Valium 10-20mg or phenytoin sodium 15-20mg/kg, no long-term treatment is needed;
⑤ Central hyperthermia: it is advisable to first physical hypothermia, if the effect is not good, dopaminergic agonist such as bromocriptine 3.75mg/d, gradually increase the dose to 7.5~15.0mg/d, divided into doses; also can be used nifedipine 0.8-2.5mg/kg, intramuscular or intravenous administration, 6~12 hours once, after remission with 100mg, 2 times / d;
(6) Lower limb deep vein thrombosis: Progressive swelling and stiffness of the limb, can be prevented by turning over, passive activity or elevating the paralyzed limb, once it occurs, the limb venous hemogram should be examined, and common heparin 100mg should be given intravenously once a day, or low molecular heparin 4000IU subcutaneously twice a day.
2.Surgical treatment
Surgical treatment of cerebral hemorrhage is beneficial to save the life of critically ill patients and promote the recovery of neurological function. It should be decided according to the bleeding site, etiology, bleeding volume and the patient’s age, state of consciousness and general condition. Surgery should be performed at an ultra-early stage (within 6-24h after the onset).
(1) Indications for surgery.
Surgery can be considered if the following patients do not have significant dysfunction of important organs such as heart, liver and kidney.
① Patients with cerebral hemorrhage gradually develop signs of increased intracranial pressure with brainstem compression, such as slow heart rate, elevated blood pressure, slowed whistling rhythm, decreased level of consciousness, or with actinic nerve palsy;
(ii) Hematoma of cerebellar hemisphere hemorrhage >15ml, earthworm hematoma >6m1, hematoma breaking into the fourth ventricle or brain pool pressure disappears, and brainstem pressure symptoms or signs of acute obstructive hydrocephalus appear;
(iii) obstructive hydrocephalus due to ventricular hemorrhage;
④Young patients with hemorrhage in the brain lobes or shell nucleus to a large amount (>40~50m1), or with clear vascular lesions (such as aneurysm, arteriovenous malformation and cavernous hemangioma). Cerebral bridge hemorrhage is usually not suitable for surgery.
(2) Commonly used surgical methods.
① craniotomy for hematoma removal.
(ii) Borehole enlargement of the bone window for hematoma removal.
(iii) Cone-hole perforation hematoma aspiration.
④ stereotactic hematoma arch [flow operation.
⑤ Ventricular drainage: for ventricular hemorrhage.
3.Rehabilitation treatment
After cerebral hemorrhage, as long as the patient’s vital signs are stable, the condition is stable and progress is stopped, rehabilitation therapy is appropriate as early as possible. Early rehabilitation will be beneficial to restore the patient’s neurological function and improve the quality of life. Pharmacological treatment and psychological support, such as fluoxetine 10-20mg orally once a day, should be given in time for the possible depression of the patient.
Acute phase rehabilitation.
1.Keeping the correct posture of bed lying: is the success or failure of rehabilitation.
2.Training to maintain joint mobility: It can maintain the normal range of motion of joints, effectively prevent muscle atrophy and promote the recovery of whole body function. Treat twice a day for 10-20 minutes each time, and do full range of motion exercises for 2-3 times for each joint of the whole body in each direction of motion.
3, leave the bed as early as possible to take a sitting position, to ensure the correct sitting position in the chair and wheelchair.
4.Transfer movement training.
5.Self-assisted training of upper limbs.
6.Scapular training: prevent the scapular muscle spasm.
Rehabilitation of spasticity period: it is required to proceed in stages from simple to complex overload, from single joint to multi-joint activities, from plane to standing and space activities, gross to fine motor activities. Specific methods are as follows.
1, to promote the normalization of muscle tension and exercise randomness.
(1) Training performed in the supine position.
a. Training to inhibit spasm of the extensor muscles of the lower limbs.
b. Training for control of lower limb flexion and extension.
c. Preparatory training for weight-bearing of the lower limbs.
d. Control training of hip joint adduction and abduction.
e. Control training of hip extension.
f.Sit-up training from supine position.
(2) Training in the sitting position.
a.Sitting balance training.
b. Upper limb support training on the affected side.
2. Transfer movement training.
(1)Sit up in bed
(2) Sitting up training
(3)Bed to wheelchair transfer
(4) Sitting and standing up training Face-to-face activities
3.Control training of upper limb movement.
(1)Training activities in the supine position.
a. Suppression of spasticity.
b. Training of active movement and control of upper limbs.
(2) Training activities under sitting position: a. Training of voluntary movement of elbow joint.
a.Autonomous movement training of elbow joint.
b. Weight-bearing training for upper limb support.
c. Daily training contents that the patient should master.
(3) Activities under the standing position.
a.Standing training along with upper limb control training.
b. Training activities to improve standing balance and promote eye-hand coordination.
c.Operational activities useful for physical recovery.
4.Walking training.
(1) Stance and standing balance training.
(2) Training for functions required during the support period.
(3) Training for the functions required in the striding period.
(4) Training in the kneeling position.
(5) Walking training in the double bar.
(6) Walking with crutches.
(7) Step-up and step-down training.
Daily life movement training: living movement, eating, grooming movement, toileting movement, dressing movement, bathing movement, cooking movement.
4.Special treatment
① Non-hypertensive cerebral hemorrhage: if coagulation abnormalities can be corrected with fresh frozen plasma and vitamin K or intravenous fisetin; cerebral hemorrhage complicated by thrombolytic therapy can be treated with fisetin and 6-aminocaproic acid; cerebral hemorrhage caused by hemophilia can be treated with supplemental lack of coagulation factors or fresh plasma; patients with leukemia, aplastic anemia and other abnormal platelet function should Platelet input; aspirin, ticlopidine and other anti-platelet drugs caused by cerebral hemorrhage can be discontinued, drug abuse caused by cerebral hemorrhage should be discontinued immediately;
② Multiple cerebral hemorrhage: hypertensive atherosclerosis, amyloid angiopathy, cerebrovascular malformation, tumor stroke, hematologic diseases are common causes; usually the condition is serious and the prognosis is poor, the cause should be actively searched for and the etiology should be treated.
③ Prevention and treatment of rebleeding: the reoccurrence rate of cerebral hemorrhage is about 10%, and adjustment of blood pressure is the most critical.
④ Unstable cerebral hemorrhage: it can be due to high blood pressure, long-term heavy drinking or related to inappropriate moving after the onset of the disease; CT shows hematoma edge irregularity, uneven density and irregular shape, the condition can continue to worsen or deteriorate rapidly, or once stable and then suddenly worsen, close monitoring should be done, timely review of cranial CT, and strengthening of therapeutic measures. Brain hemorrhage is one of the most serious types of stroke. With the effective control of stroke risk factors such as hypertension, its incidence is decreasing; however, the morbidity and mortality rate is still high, ranging from 35% to 52% within 30 days after the disease, and more than half of the deaths occur within 2 days after the disease; cerebral edema, increased intracranial pressure and brain hernia formation are the main causes of death. The prognosis is related to the amount and location of hemorrhage, etiology and general condition. Brainstem, thalamus and massive ventricular hemorrhage have a poor prognosis. The number of patients who can resume self-care is about 10% after 1 month and about 20% after 6 months, and some patients can return to work.