Overview
Intracerebral Hemorrhage (ICH) is one of the most common refractory diseases in neurosurgery, accounting for 25%-55% of strokes in Asian countries, but only 10%-15% of strokes in Europe and the United States. Patients are left with disabilities, which is one of the major causes of death and disability in the Chinese population. The standardization of diagnostic criteria and treatment techniques for ICH can help reduce the mortality and disability rates.
Classification of cerebral hemorrhage
The risk factors and etiologies of cerebral hemorrhage are mostly associated with hypertension, Cerebral Amyloid Angiopathy (CAA), cerebral arteriovenous malformation, cerebral aneurysm, tumor stroke, and coagulation dysfunction. In Europe, ICH is classified as primary cerebral hemorrhage, secondary cerebral hemorrhage, and cerebral hemorrhage of unknown origin; in the United States, some scholars have named ICH as non-aneurysmal, non-AVM, and non-tumor spontaneous cerebral hemorrhage. The classification of primary and secondary cerebral hemorrhage is now more recognized.
Secondary cerebral hemorrhage generally refers to cerebral hemorrhage with a clear etiology, mostly caused by cerebral arteriovenous malformation, cerebral aneurysm, use of anticoagulant drugs, thrombolytic therapy, antiplatelet therapy, coagulation dysfunction, brain tumor, cerebral vasculitis, dural arteriovenous fistula, smoker’s disease, venous sinus hemoptysis formation, etc. It accounts for 15-20% of ICH.
Primary cerebral hemorrhage refers to cerebral hemorrhage without a clear etiology, mostly combined with {blood pressure. In China, although no large sample of epidemiological investigation has been conducted, the name “hypertensive cerebral hemorrhage” has been used in China because of the lack of a large sample of epidemiological investigation. In foreign medical literature, the disease is mostly referred to as cerebral hemorrhage or spontaneous cerebral hemorrhage, accounting for about 80%-85% of all ICH.
This guideline is limited to the diagnosis and treatment of primary cerebral hemorrhage.
Auxiliary examinations
1.Imaging examination
CT and MRI can reflect the site of hemorrhage, the amount of hemorrhage, the extent of the hemorrhage and the brain tissue around the hematoma.
(1) CT scan: widely used, ICH appears as a high-density shadow on CT, and is the imaging test of choice for stroke diagnosis. Currently, there is software that can accurately calculate the hematoma volume based on CT images.
(2) Multi-modality CT scan: including CT cerebral perfusion imaging (CTP) and enhanced CT. CTP can reflect the changes of blood supply in brain tissue after ICH and can understand the blood perfusion around the hematoma. Contrast spillage on enhanced CT scan is an important evidence that the patient is at high risk of hematoma expansion.
(3) MRI scan: The presentation of ICH on MRI is complex and varies according to the duration of the hematoma: hyperacute phase (0-2h): the hematoma is T1 low signal and T2 high signal, which is not easily distinguishable from cerebral infarction; acute phase (2-72h): T1 isosignal and T2 low signal; subacute phase (3 days-3 weeks): both T1 and T2 are high signal; chronic phase (>3 weeks). MRI is superior to CT in detecting chronic hemorrhage and cerebrovascular malformations, but MRI is more time-consuming, more expensive, and generally not the imaging of choice for ICH.
(4) Multi-modality MRI scans: These include diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), water suppression imaging (FLAIR), gradient echo sequences (GRE), and magnetically sensitive weighted imaging (SWI), which can provide additional information on ICH. For example, SWI is more sensitive to early ICH and microhemorrhage.
2.Cerebrovascular examination
Cerebrovascular examination can be used to detect the cause of ICH and exclude secondary cerebral hemorrhage, and to guide the development of treatment plans. Commonly used tests are CTA, MRA, CTV, DSA, etc.
(1) CTA, MRA, CTV, MRV: These are common methods for rapid, non-invasive evaluation of intracranial and extracranial arterial vessels, venous vessels and venous sinuses.
(2) Whole brain angiography (DSA): it can clearly show all levels of cerebral vascular branches, and can clarify the presence of aneurysms, AVM and other cerebrovascular lesions, and can clearly show the location, size, morphology and distribution of lesions, and is still the vascular lesion detection.
3.Laboratory examination
Routine laboratory tests should be performed on patients suspected of having ICH.
Diagnosis
ICH is generally not difficult to diagnose based on clinical signs and symptoms such as sudden onset, severe headache, vomiting, and neurological dysfunction, combined with CT and other imaging tests. However, there is no gold standard for the diagnosis of primary cerebral hemorrhage, especially hypertensive cerebral hemorrhage, and various secondary cerebral hemorrhage diseases must be excluded to avoid misdiagnosis, and all of the following criteria must be met to make the final diagnosis.
1, a definite history of hypertension.
2, typical site of hemorrhage: (including basal ganglia area, ventricles, thalamus, brainstem, cerebellar hemispheres).
3, DSA/CTA/MRA to exclude secondary cerebrovascular disease.
4, early (within 72 hours) or late (after 3 weeks of hematoma disappearance) enhanced MRl examination serving cowardly disaster faceted oyster C pyrimidine chimney dangers CM) and other diseases.
5.Exclude various coagulation disorders.
Treatment
1.Medical treatment
Patients with ICH are often unstable during the first few days of illness. They should be routinely and continuously monitored for vital signs (including blood pressure monitoring, ECG monitoring, oxygen saturation monitoring) and regular neurological assessment, closely observe the condition and changes in hematoma, and resend Van CT regularly, especially for patients who have their first head CT within 3 hours of onset, and should resend Van CT again within 8 hours and 24 hours at the latest after onset.
The first principle of ICH treatment is to keep quiet, stabilize blood pressure, prevent continued bleeding, lower intracranial pressure appropriately according to the situation, prevent and control cerebral edema, maintain water-electrolyte, blood sugar and body temperature balance; meanwhile, strengthen respiratory management and care, prevent and protect against various intracranial and systemic complications.
(1) Blood pressure control.
Patients with acute cerebral hemorrhage are often accompanied by significant blood pressure rise {and the magnitude of blood pressure rise usually exceeds that of patients with ischemic stroke, which increases the risk of disability and death in patients with ICH. Three studies, the Acute Cerebral Hemorrhage Antihypertension Study (ATACH) and the Acute Cerebral Hemorrhage Aggressive Antihypertensive Therapy Study (INTERACT, INTERACT-2), provide an important basis for early blood pressure lowering in patients with ICH.
The studies showed that controlling systolic blood pressure below 140 mm Hg reduced the incidence of hematoma enlargement without increasing adverse events, but did not significantly improve the rate of death and disability at 3 months. Rapid blood pressure control with medications should be used early in cerebral hemorrhage and immediately after hematoma removal, but it is also important to avoid the decrease in cerebral blood flow that may result from too rapid and too low a drop in blood pressure in patients with chronic severe hypertension. If abnormally elevated blood pressure is caused by CUSHING’ reaction or central causes, treatment should be directed at the cause and should not be done simply by blindly lowering blood pressure.
Commonly used intravenous antihypertensive drugs: nicardipine, uradil, nitroglycerin, etc.
Commonly used oral antihypertensive drugs: long-acting calcium channel blockers, angiotensin II receptor blockers, β1 adrenergic receptor blockers, etc.
(2) Reduce intracranial pressure and control cerebral edema.
Elevate the head of the bed about 30° with the head on the midline to increase jugular venous return and lower intracranial pressure.
For patients requiring tracheal intubation or other similar operations, intravenous sedation is required. Sedation should be gradually increased to minimize the rise in intracranial pressure caused by pain or agitation {. Commonly used sedative drugs include: diisoprostanes, etomidate, midazolam, etc. Analgesics include: morphine, alfentanil, etc.
(3) Drug treatment: If the patient has clinical or imaging manifestations of increased intracranial pressure, and/or the measured ICP>20mmHg, dehydrating agents such as 20% mannitol (1-3g/Kg/day), glycerol fructose, hypertonic saline, albumin, diuretics, etc. should be applied to monitor renal function and electrolytes to maintain the stability of the internal environment; if necessary, intracranial pressure monitoring is feasible.
(4) Blood glucose management.
Regardless of previous diabetes, hyperglycemia on admission predicts an increased risk of death and poor regression in patients with ICH. However, hypoglycemia can lead to cerebral ischemic injury and cerebral edema, so it also needs to be corrected promptly. Therefore, blood glucose should be monitored and controlled within the normal range.
(5) Hemostatic drugs.
Hemostatic drugs can be applied appropriately within 8 hours of hemorrhage to prevent hematoma expansion, and their use generally does not exceed 48 hours. For patients with normal coagulation function, the routine use of hemostatic drugs is generally not recommended.
(6) Anti-vascular spasm therapy.
For patients with combined subarachnoid hemorrhage, calcium channel antagonists (nimodipine) can be used.
(7) Hormonal therapy.
Still controversial. Patients with hypertensive cerebral hemorrhage have no significant benefit from hormonal therapy and are at increased risk for complications (e.g., infection, gastrointestinal bleeding, and hyperglycemia). Short-term hormone therapy with methylprednisolone, dexamethasone, or hydrocortisone may be considered if there is significant edema on imaging.
(8) Airway management.
If the degree of impaired consciousness, poor sputum excretion or pulmonary infection can be considered tracheal intubation or early tracheotomy, sputum excretion to prevent pulmonary infection, patients suspected of pulmonary infection, should be early sputum culture and drug sensitivity test, the choice of effective antibiotic treatment.
(9) Neuroprotective agents.
Whether to use neuroprotective agents after cerebral hemorrhage is still controversial, but some clinical reports show that neuroprotective agents are safe and tolerable, and have improved clinical prognosis.
(10) Temperature control.
General control of body temperature in the normal range, there is no conclusive evidence to support hypothermia treatment.
(11) Stress ulcer prevention.
Proton pump inhibitors can be used early in cerebral hemorrhage to prevent stress ulcers.
(12) Maintenance of water and electrolyte balance.
Regular check-ups of search swish molasses boilers and light yellow eyes
(13) Anti-epileptic treatment.
Anti-epileptic drug therapy should be administered if clinical epileptic seizures occur. It is inconclusive whether to use medication for seizure prevention in patients without seizures. Many surgeons advocate seizure prophylaxis for patients with large supratentorial hematomas or after supratentorial surgery.
(14) Prevention of lower extremity deep vein thrombosis and pulmonary embolism.
Patients with ICH are at higher risk of deep vein thrombosis and pulmonary embolism, and should be encouraged to move early and leg elevation to avoid puncturing lower extremity veins for infusion whenever possible, especially on the paralyzed side of the limb; elastic stockings and intermittent air compression devices can be used in combination to prevent lower extremity deep vein thrombosis and related embolic events.
2.Surgical treatment
The main goal of surgical treatment in China is to promptly remove the hematoma, relieve cerebral compression, relieve severe intracranial hypertension and brain herniation, save the patient’s life, and minimize the secondary brain injury and disability caused by hematoma compression.
(1) Hemorrhage in the basal ganglia
Surgical indications: emergency surgery can be considered if there is one of the following manifestations: herniation of temporal lobe hook gyrus; CT, MRI and other imaging examinations of 5mm; compression and occlusion of more than 1/2 of the ipsilateral lateral ventricle; blurring or disappearance of the ipsilateral brain pool and sulcus); actual measurement of intracranial pressure (ICP) >25mmHg.
(2) Surgical procedures and methods
Bone flap craniotomy for hematoma removal
Generally, the temporal flap or frontotemporal flap on the side of the lesion is opened, and the middle temporal gyrus or lateral fissure is accessed through the middle temporal gyrus or lateral fissure, and the hematoma cavity is reached by cerebral needle puncture in the non-vascular or less-vascular area, and after the aspiration is confirmed to be old blood or blood clot, the middle temporal gyrus or insula cortex is incised or separated by about 0.5-1.0 cm and probed with the side of the cerebral pressure plate.
Although it is slightly more traumatic to the scalp and skull, the bone flap craniotomy can completely remove the hematoma under direct vision, with reliable hemostasis and rapid decompression, and it can also decide whether to perform bone flap decompression according to the patient’s condition and intracranial pressure changes during the operation.
Small bone window craniotomy for hematoma removal.
The small bone window craniotomy has little damage to the scalp and skull, and the surgical procedure is relatively simple, which can remove the hematoma quickly and stop the hemorrhage satisfactorily under direct vision.
A skin incision parallel to the lateral fissure projection line is made on the patient’s temporal bone, about 4-5 cm long, 1-2 holes are drilled in the temporal bone, and a free bone flap of about 3 cm in diameter is milled with a milling knife, and the dura cross is cut. The cerebral needle is punctured in the superior temporal gyrus or middle temporal gyrus to determine the site of the hematoma and then a cortical incision is made, which is approximately 1 cm long. After complete hemostasis and confirmation of good cerebral pressure and pulsation, the dura was sutured, the skull bone flap was fixed, and the scalp was sutured layer by layer.
Neuroendoscopic hematoma removal
A combination of rigid microscopy and stereotactic techniques is used to remove the hematoma. The hematoma cavity is punctured under CT or B ultrasound positioning, and the hematoma is removed as much as possible without damaging the vessel wall, surrounding brain tissue and causing new bleeding, but it is not necessary to force complete removal to avoid causing new bleeding, and it is sufficient to achieve the purpose of decompression, and then a drainage tube is placed for external drainage, and in case of small arterial bleeding, the bleeding can be stopped by high-frequency radiofrequency coagulation through the working channel of the endoscope.
Stereotactic bone hole hematoma aspiration (modified vertebral craniotomy)
According to the CT localization of the hematoma site, stereotactic head frame positioning or ruler positioning is used to avoid important blood vessels and functional areas, local infiltration anesthesia is selected, small straight incision (2 cm) is made to cut the scalp, the dura is cut after drilling, and the hematoma is punctured under direct vision using disposable intracranial hematoma crushing puncture needle or common suction and other instruments, the first aspiration of the hematoma volume is not limited and should be aimed at decompression, and the hematoma cavity is left to drain The hematoma cavity should be left to drain for 3-5 d. The drainage channel or drainage tube should be left in place for continuous drainage.
(3) Key points of surgery
Regardless of the access and procedure, new damage to brain tissue caused by surgery should be avoided or minimized, and the following precautions should be followed.
To operate as delicately as possible under the microscope.
special attention should be paid to the protection of brain tissue, the lateral fissure vein, the middle cerebral artery and its branches and the unruptured bleeding doublestem artery.
Cortical incision generally not exceeding 2 cm, keeping the operation free of traction or light traction, keeping the traction within 40 mmHg.
Light suction and weak electrocoagulation, keeping the operation within the hematoma cavity to avoid damaging the brain tissue and blood vessels around the hematoma.
(4) Postoperative treatment
Blood pressure control: same as medical treatment.
Infection control: Intracranial infection is mostly related to invasive operations (surgery, drilling, lumbar puncture, etc.), and is usually high around 3 days after surgery, with symptoms such as headache, persistent high fever, positive meningeal irritation signs, etc. Cytological examination of cerebrospinal fluid in the lumbar puncture or drainage tube.
a. Selection of effective and sensitive antibiotics.
b, lumbar puncture or lumbar pool puncture for drainage of cerebrospinal fluid.
c. Immunity-boosting therapy (active or passive immunotherapy).
d. Control of body temperature and prevention of secondary damage.
Pulmonary infection: Patients who are unconscious after cerebral hemorrhage have a higher incidence of pulmonary infection. Attention should be paid to pulmonary infection control and airway management.
a. Tracheal intubation or tracheotomy should be considered for comatose patients.
b. Keep the airway open to prevent and control pulmonary infections.
c. Patients with suspected pulmonary infection, early sputum culture and drug sensitivity test, and treatment with sensitive and effective antibiotics.
d. Enhance systemic nutritional support.
e. Pay attention to respiratory management, effective sputum removal, oral care, early ventilator support for those with respiratory dysfunction and decreased oxygen saturation.
Body temperature control.
Causes of elevated body temperature.
a. Intracranial hematoma stimulation: intraventricular hemorrhage, subarachnoid hemorrhage.
b. Infection: systemic and intracranial, pulmonary and other organ infections in various parts of the body.
c. Central hyperthermia: brainstem thalamic hemorrhage or brain herniation followed by dysfunction of the central temperature center.
Cooling measures include treatment of infection, physical cooling and subcold temperature treatment. The goal of cooling is to control the body temperature in the normal range and try not to go below 35°C, but the prolonged use of subcold temperature therapy is not recommended.
Internal environment stabilization: maintain the stability of the internal environment, correct electrolyte disorders in a timely manner, and control random blood glucose below 11.1 mmol/L.
Nutritional support
Indications for postoperative nutritional support in patients with hypertensive cerebral hemorrhage.
a. Patients with preoperative malnutrition need to be given nutritional support after surgery.
b, some patients with slow recovery of gastrointestinal function after surgery, who cannot resume normal diet within 2-3 days.
c, surgery trauma, patient recovery is slow, can not resume regular diet within a short period of time.
However, not every postoperative patient needs nutritional support. Patients who can resume about 60% of their diet within a week or patients without malnutrition generally do not need nutritional support. For patients with chronic respiratory, renal or hepatic dysfunction or elderly patients, postoperative nutritional support is not required unless they have severe malnutrition.
In principle, trans-enteral nutrition is the first choice for postoperative nutritional support, and parenteral nutrition and trans-enteral nutrition can be applied alternately or simultaneously. The amount of nutritional support should be 25-30 KCAL/kg per day according to body weight, and the amount of energy supply should be increased as appropriate in case of co-infection and hyperthermia.
Postoperative rebleeding or cerebral infarction.
Judgment of postoperative rebleeding or cerebral infarction: postoperative rebleeding or cerebral infarction should be highly suspected in the occurrence of the following conditions, and prompt re-CT is required
a. Deepening of the impairment of consciousness.
b, unequal pupil changes or bilateral pupil dilatation, especially on the surgical side, often suggesting the possibility of elevated intracranial pressure and cerebral herniation.
c, elevated blood pressure or cushing reaction.
d, poor movement or decreased muscle strength of one limb and decreased pain stimulation response.
e. Intracranial pressure monitoring shows elevated intracranial pressure.
Other complications management: same as medical treatment.
Thalamic hemorrhage
Surgical indications: same as for cerebral hemorrhage in the basal ganglia region.
Surgical methods: various hematoma removal surgeries: refer to basal ganglia cerebral hemorrhage; external drainage of ventricular borehole; for patients with thalamic hemorrhage breaking into the ventricle, small thalamic parenchymal hematoma, but occurrence of obstructive hydrocephalus and secondary intracranial hypertension, generally perform external drainage of lateral ventricular frontal horn borehole.
Surgical points and postoperative management: refer to blood in the basal ganglia.
Lobar hemorrhage: refer to basal ganglia hemorrhage
Ventricular hemorrhage
Small to moderate amount of hemorrhage, patient is conscious, GCS>8, no obstructive hydrocephalus, conservative treatment or continuous external drainage of the lumbar pool; larger amount of blood, more than 50% of the lateral ventricle, GCS<8, combined with obstructive hydrocephalus. External drainage of the ventricular borehole is performed. If the bleeding volume is large, exceeding 75% of the lateral ventricle volume or even ventricular cast, with GCS < 8 points and obvious intracranial hypertension, craniotomy is required to remove intracerebroventricular hematoma directly.
Surgical points and postoperative management: refer to basal ganglia hemorrhage
Cerebellar hemorrhage
Surgical indications: hematoma over 10 ml, compression or complete occlusion of the four ventricles, obvious occupying effect and intracranial hypertension; patients with brain herniation; combined with obvious obstructive hydrocephalus; actual measurement of intracranial pressure (ICP) > 25 mmHg.
Surgical approach: subscapular median or paramedian approach with bone flap craniotomy for hematoma removal.
Surgical points and postoperative management: refer to brain hemorrhage in the basal ganglia.
Brainstem hemorrhage
Severe brainstem hemorrhage has a high mortality and disability rate with conservative treatment, and surgical treatment has been explored and reported in China, which can help reduce the mortality rate. However, the indications for surgery, procedure and efficacy need to be further studied and summarized.
This article is from the 2015 China Stroke Conference, designated by the Stroke Prevention and Control Engineering Committee of the National Health and Family Planning Commission, Stroke Prevention and Control Series Guideline Editorial Review Committee.