Hypertensive cerebral hemorrhage (HICH) is a primary hemorrhagic disease in the brain parenchyma secondary to hypertension. HICH has an acute onset, a severe disease, a high mortality rate (40%-50%) and a high disability rate (50%-85% of survivors), and its causes of disability and death are mainly the intracranial occupancy of the acute hematoma and a series of pathological changes caused by the bleeding itself on the brain and vascular damage. The current status and progress of the treatment of HICH are reviewed as follows.
I. Internal treatment
1. Blood pressure management
Blood pressure is often significantly elevated in patients with acute HICH. Some patients’ blood pressure will drop spontaneously after a few days, while others will continue to have high blood pressure. In addition to pre-morbid hypertension, stress and elevated intracranial pressure also contribute to elevated blood pressure in the acute phase of cerebral hemorrhage. Theoretically, hypertension can cause hematoma enlargement and perihematoma edema, increasing the risk of rebleeding. the INTERACT trial, an open randomized controlled study, suggests that early blood pressure lowering in cerebral hemorrhage is safe. the ATACH trial also confirmed that early rapid blood pressure lowering in patients with cerebral hemorrhage is feasible and safe; however, the effectiveness is not yet clear.
2. Glycemic control
Patients with HICH with high blood glucose on admission have a poorer prognosis and increased risk of death, regardless of the presence or absence of diabetes. A randomized trial of critically ill patients showed that tight glycemic control with insulin improved patient prognosis, but recent studies have found that tight glycemic control increases the incidence of hypoglycemia and reduces brain supply increasing the risk of patient death. The 2010 AHA guidelines for cerebral hemorrhage recommend monitoring blood glucose and maintaining it at normal levels (Class III recommendation, Class C evidence).
3. Temperature control
Patients with basal ganglia and lobar hemorrhage have a high incidence of fever, especially in patients with combined ventricular hemorrhage. Patients with febrile cerebral hemorrhage have a poor prognosis. Ma Jun’s study showed that local subhypothermia treatment can reduce local brain edema in patients with acute cerebral hemorrhage, promote neurological recovery and significantly improve the prognosis.
4. Epilepsy and antiepileptic treatment
Seizures secondary to the onset of cerebral hemorrhage often occur in the acute phase, and some are the first symptoms, with an incidence of 5% to 15%. In a group of patients with cerebral hemorrhage in whom most patients received prophylactic antiepileptic therapy, continuous EEG monitoring revealed seizures on the EEG in 21% to 31% of patients. A prospective population-based study found that clinical seizures were not associated with worsening neurological function or mortality. 2010 AHA guidelines for cerebral hemorrhage recommend antiepileptic therapy for seizure-like episodes with clinical seizures (Class I recommendation, Level A evidence); if altered mental status is disproportionate to the brain injury and 24-h EEG monitoring is indicated (Class II recommendation, Level B evidence); and if altered mental status is associated with Patients with EEG seizure waves should be given antiepileptic treatment (Grade III recommendation, Grade C); prophylactic antiepileptic treatment is not recommended (Grade II recommendation, Grade B); if seizures occur again 2 to 3 months after stroke, long-term drug treatment should be given according to the conventional treatment of epilepsy (Grade IV recommendation, Grade D).
5. Management of high cranial pressure
The treatment of intracranial hypertension should directly target the causes of intracranial hypertension. The causes of intracranial hypertension in patients with cerebral hemorrhage are mainly the occupying effect of cerebral hematoma and cerebral edema. Clinical implementation is mainly based on the principles of intracranial hypertension treatment in the brain injury guidelines, emphasizing the need to maintain cerebral perfusion pressure at 50-70 mmHg while reducing intracranial pressure.
Second, surgical treatment
Surgical treatment of HICH surgical modalities, indications and surgical time window are still no uniform standards.
1, surgical indications: comprehensive literature its indications are more uniform views are as follows.
(1) Patients awake with moderate to massive bleeding usually subcortical and nucleus accumbens bleeding >30ml.
(2) Patients with cerebellar hematoma >10 ml, hematoma diameter >3 cm, with brainstem compression and with hydrocephalus.
(3) Moderate to massive lobar hemorrhage with some degree of preserved consciousness and neurological function after hemorrhage, followed by gradual deterioration, should be treated with aggressive surgery to save life.
(4) Young patients.
(5) Microinvasive hematoma removal with only minor injuries, and the indications can be relaxed appropriately.
2.Surgical timing: At present, most tend to medium and small amount of bleeding surgery timing 6 to 24h is appropriate, large amount of bleeding should be operated in time to save life, according to the specific situation of the patient to be flexible.
3.Surgical methods.
(1) large bone flap craniotomy hematoma removal: at present, it is mostly used for patients with large amount of bleeding, serious midline displacement, preoperative condition grading above grade III and signs of brain herniation formation but for a short period of time. Its advantage is that it can remove deep hematoma and intracerebroventricular blood under direct vision, with reliable hemostasis; at the same time, it can decompress the bone flap and quickly release the compression of brain tissue, so it is the most performed surgical method at present. The disadvantages are that it requires general anesthesia, large surgical trauma, long operation time, more bleeding, heavy postoperative edema reaction, easy to have postoperative complications, and high patient mortality rate.
(2) Small bone window craniotomy: Small bone window craniotomy is also known as neurosurgical “lock hole” surgery, which can design the surgical approach according to the characteristics of the lesion, make full use of the limited space, select a small cortical incision under microsurgical techniques, safely and reliably remove the blood clot, precisely reveal and control the bleeding point, and protect the tiny It can make full use of the limited space, select a smaller cortical incision, safely and reliably remove the blood clot, precisely reveal and control the bleeding point, and protect the small penetrating vessels, thus causing less damage to brain tissue. However, this method cannot provide effective decompression in cases of significant brain tissue swelling.
(3) Ventricular puncture and external drainage, hematoma lysis: ventricular puncture is suitable for some critical patients with intraventricular hemorrhage or hematoma breaking into the ventricles, which can be performed before other surgical procedures are chosen to lower the intracranial pressure and buy rescue time. Depending on the situation, unilateral or bilateral external drainage can be selected, and thrombolytic drugs can be applied simultaneously for intracavitary injection of the hematoma to facilitate postoperative drainage. The advantages of ventricular puncture are that the operation time is short, it is performed under local anesthesia, it can reduce the intracranial pressure, it can continuously drain the ventricular hematoma and reduce the pressure of the hematoma on the brain tissue, and the method is simple and easy to perform; its disadvantage is that the external drainage of the ventricle to remove the hematoma is not complete and cannot effectively stop the bleeding.
(4) Minimally invasive hematoma crushing and aspiration: using YL-1 intracranial hematoma crushing puncture needle and thrombolytic drugs to aspirate, liquefy and drain the intracranial hematoma in order to remove the hematoma. This method is simple and fast, can quickly establish a hard channel to remove the hematoma and fixed on the skull, stability and confinement are better, and the fluid flow ejected from the flushing needle is in the form of mist, so that the liquid acts on the blood clot in a large area and is easy to liquefy. However, its shortcomings are that it cannot be operated under direct vision, the removal of hematoma is not complete, it cannot effectively stop bleeding, the diameter of the drainage tube is small, and the puncture positioning is not accurate. In recent years, soft channel puncture and drainage techniques have also been popularized.
(5) CT-guided or stereotactic hematoma placement and drainage: In 1978, the application of stereotactic technique was first reported for sub-total evacuation of intracranial hematoma, and this method is a minimally invasive hematoma removal operation. intracavitary injection of the hematoma to facilitate postoperative drainage. It is an accurate localization, less traumatic, convenient, fast, safe and effective microinvasive treatment method.
(6) Ultrasound-guided hematoma removal: mediated human ultrasound-guided hematoma removal has the advantages of small bone window, accurate and fine operation, and accurate puncture and aspiration for small hematomas in important functional areas of the brain or small hematomas in the thalamus.
(7) Neuroendoscopy-assisted hematoma removal: this method is operated under endoscopy, which can provide good illumination and clear magnified images, enabling the operator to clearly observe and remove the hematoma and stop the hemorrhage, and the laser technology supporting the endoscope provides convenience for hemostasis after hematoma removal, and can retain the advantages of microbony window craniotomy, with less damage, easier control of deep bleeding and protection of the hematoma wall, and can achieve the goal of proper hemostasis of the opposite wall. The purpose of proper hemostasis of bleeding.
Third, Chinese medicine research
1.Application of the method of activating blood circulation and removing blood stasis
With the interpenetration of Chinese and Western medicine, it is clear that cerebral hemorrhage is a hemorrhage of brain parenchyma in the skull, and many scholars have discussed cerebral hemorrhage clinically from the perspective of blood stasis in combination with Chinese medicine theory. At present, there are two different views on whether it is safe to use large doses of blood-stasis activating drugs in the early stage of cerebral hemorrhage. Liu Fenghua et al. believed that the application of blood-stasis activating drugs in the early stage of acute cerebral hemorrhage could significantly reduce the morbidity and mortality rate and disability rate of patients. However, some scholars believe that treatment with blood-activating and stasis-transforming drugs should be taken with caution in the ultra-early stage of cerebral hemorrhage.
2.The application of the method of venting heat from the internal organs
Although cerebral hemorrhage is stasis in the brain, it can affect the internal organs such as lung, stomach and intestines, resulting in heat and stasis intertwined and manifesting as internal stagnation of heat. According to Lu Yanchun and others, the acute stage of cerebral hemorrhage is mainly focused on the symptoms of the standard reality, at this time, the use of the method of venting heat from the internal organs can attack and expel phlegm and stagnant blood, unblock the internal qi, eliminate toxins, and play the effect of “pulling out the fire from the bottom”, and has the function of lowering intracranial pressure and eliminating hematoma.
3.Application of phlegm and stasis treatment method
The clinical study on the application of Luo Lebo’s treatment of cerebral hemorrhage by dispelling stasis, resolving phlegm and clearing blood vessels shows that the method of treating phlegm and stasis together has good effect on promoting patients’ recovery and reducing the mortality and disability rate, with the total effective rate reaching 82.1%.
IV. Outlook
HICH is a common neurological disease in middle-aged and elderly people, with high disability and death rates. Once a cerebral hemorrhage occurs, the patient should be promptly sent to the hospital to determine whether the patient is still bleeding by current advanced imaging technology, to reduce the increase of hematoma using measures such as blood pressure control, to promptly operate to relieve the damage to brain tissue caused by the hematoma, to control all factors that may aggravate clinical symptoms, and to promote the patient’s recovery. There are still no effective interventions for cerebral hemorrhage, and there is a long way to go to strengthen clinical treatment research.