1.Category of cerebral hemorrhage
Traumatic – epidural, subdural, intracerebral hemorrhage
Non-traumatic – hypertensive cerebral hemorrhage, subarachnoid hemorrhage (intracranial aneurysm, cerebrovascular malformation)
Other: blood disorders, brain tumor bleeding, coagulation abnormalities, etc.
2.Hypertensive cerebral hemorrhage
(1) Definition: Hypertensive cerebral hemorrhage, also known as cerebral hemorrhage or hemorrhagic stroke, refers to the occurrence of bleeding in the brain parenchyma in the presence of high blood pressure. Specifically, intracerebral hemorrhage occurs due to cerebrovascular lesions caused by hypertension.
(2) Characteristics.
a. High incidence: The annual incidence of cerebrovascular disease is 150-200 people/100,000, of which 75%-85% are ischemic and 10%-15% are cerebral hemorrhage
b, high mortality: mortality rate of 40-60%, of which 50% died within 24h, 75% died within three days
c, high disability rate: 50-85% of survivors, low quality of survival
d, high recurrence rate: the annual re-bleeding rate of 2% ~
(3) Etiology
a, 1734, Wepfer cerebral artery rupture
b, 1928, Abercrombie cerebral vascular wall lesion hypothesis
c. Pathological basis: a. Hypertension b. Chronic small arterial lesions caused by hypertension
d. Three corollaries (three doctrines)
Hemorrhage after cerebral softening
Bleeding from damage to the cerebral vessel wall
Microaneurysm formation and rupture: Microaneurysm (microaneurysm), also known as cornu aneurysm (miliary aneurysm), its formation and rupture leading to hypertensive cerebral hemorrhage is now recognized as the main pathogenesis.
e. Triggers – sudden rise in blood pressure: emotional excitement, excessive fatigue, mental stress, strenuous exercise, alcohol consumption, coughing, defecation, sudden change in temperature and cold season
(4) Pathophysiology
Primary brain damage, secondary brain damage, cerebrospinal fluid circulation disorders – increased intracranial pressure
a. Primary brain damage, direct destruction of brain tissue, severe neurological dysfunction
Blood clots —– physical, compression, pushing
b, secondary brain damage
Brain tissue edema: vasogenic edema, cytotoxic edema
Brain tissue ischemia: compression; vasospasm: blood and chemical products released by blood
Hemorrhagic material —– chemical
c. Impaired cerebrospinal fluid circulation
Intraventricular hemorrhage Hematoma breaking into the ventricle Hematoma dominant effect Brain tissue edema Cerebrospinal fluid circulation disorder ICP↑ Brain herniation
(5) Distribution of hemorrhage sites
Basal ganglia region 60%
Thalamus 10%
Lobe of the brain 10%
Cerebral bridge 10%
Cerebellum 10%
Primary ventricular hemorrhage 2%
(6) Clinical manifestations: mainly vary according to the site of bleeding, the amount of bleeding and the speed of development of bleeding.
Common manifestations include impaired consciousness, hemiparesis, aphasia, headache, vomiting, convulsions, urinary incontinence, etc.
(7) Diagnosis
① preliminary clinical judgment (omitted)
②Auxiliary examination
a. Head CT is the preferred method to diagnose intracerebral hemorrhage
rapid and accurate display of the site of bleeding, the amount of bleeding, breaking into the ventricles, the degree of cerebral edema, displacement of midline structures and dynamic observation.
Significant for the choice of treatment.
b. MRI is more sensitive than CT for the diagnosis of subacute and chronic hematomas
(8) Treatment
a. There is no uniform standard for the selection of medical and surgical treatment
Hypertensive cerebral hemorrhage is influenced by many factors such as high age, variable hematoma volume, variable hemorrhage site, variable degree of secondary brain damage after hemorrhage, and difficulty in estimating the pathological regression, so the choice of medical and surgical treatment for hypertensive cerebral hemorrhage is controversial.
Reasons: no uniform criteria for classification of hematomas.
The absence of uniform criteria for indications and contraindications to surgery
No information on large sample randomized controlled studies of surgical treatment and conservative treatment under uniform criteria.
b. Choice of medical and surgical treatment-historical review
The traditional concept was conservative treatment with unsatisfactory efficacy.
In 1903, Hayvey Cushing first proposed surgery for cerebral hemorrhage
The birth of cerebral angiography in the 1950s
In 1961, Mekissock conducted the first prospective study of 180 cases, which showed no significant difference between the two.
Hankey et al. concluded that the rate of death and disability increased after surgery.
Therefore, until the introduction of CT and the clinical application of microsurgery, most advocated the preference for medical treatment.
Surgical treatment was chosen only after brain herniation occurred, with poor efficacy, and surgeons were very reluctant to perform such procedures.
The introduction of CT has greatly simplified the diagnostic methods and has allowed accurate localization and quantification of hemorrhage, providing an important basis for choosing between conservative medical or surgical treatment.
With the widespread use of CT and the development of microsurgery, precise localization and fine surgery of hematomas became possible, and the surgical treatment of hypertensive cerebral hemorrhage once again attracted the interest of surgeons.
It has developed from a single craniotomy for hematoma removal to several surgical modalities.
c. Conservative treatment
Drugs are used to control blood pressure, prevent rebleeding and complications, reduce intracerebral edema and lower intracranial pressure. Patients have a high mortality rate (40-60%) and disability rate (50%-85% of survivors) due to the rapid onset of the disease and the number of comorbidities.
Scope of application.
1.Small amount of bleeding, consciousness and mild neurological dysfunction
2, deep coma, double pupils dilated, light reflex disappeared, irregular breathing GCS < 6 points
3, with the comprehensive treatment of surgery
d.Surgical treatment
①Objectives.
1.Removing the hematoma and relieving the compression of the surrounding brain tissue.
2.Lower intracranial pressure (ICP) and improve cerebral blood flow.
3.Relief of acute obstructive cerebral edema.
4.release and prevent brain herniation.
②Indications for surgical treatment
There is no unified standard, but generally according to the following principles
1, the amount of bleeding lobar hemorrhage, basal ganglia hemorrhage ≥ 30ml, thalamic and cerebellar hemorrhage ≥
2.Consciousness status: progressive deepening of consciousness.
3, bleeding volume although not reaching the volume of surgical indications, but the presence of severe neurological dysfunction.
③ Relative contraindications
1.Small bleeding volume, consciousness and mild neurological dysfunction
2.Brainstem functional failure.
3.Brainstem hemorrhage
4.Persons with serious systemic diseases such as heart, lung and kidney.
Timing of HICH surgery: ultra-early stage: within 6h of onset Early stage: within 72h of onset Delayed stage: > onset
The choice of the timing of surgery is more controversial
The theoretical basis for delayed surgery (4d~14d): (1) Autolysis of hematoma is easier to clear (2) Stable condition and low mortality rate (3) Low incidence of rebleeding
Although it can reduce the mortality rate of surgical treatment, it is difficult to reduce the overall mortality rate.
Early or ultra-early surgery
Most scholars now advocate early or ultra-early surgery.
Theoretical basis.
1. formation of hematoma 30 min after bleeding.
2, secondary brain damage begins to occur in the brain tissue surrounding the hematoma 6-7 h later.
3. irreversible secondary damage to the brain tissue around the hematoma can occur after 24 h.
4, Brott study found that at least 38% of the hematomas had enlarged within 24 h after cerebral hemorrhage according to CT dynamic observation.
Early removal of the hematoma can reduce the secondary damage to the surrounding brain tissue caused by the toxic effects of blood and plasma products, reduce the edema and ischemia around the hematoma, interrupt and reduce a series of secondary pathological changes after the hemorrhage, prevent the expansion of the hematoma, and reduce the intracranial pressure.
⑤Surgical methods
Open hematoma removal surgery
Small bone window hematoma removal
Stereotactic hematoma removal
Minimally invasive tube placement hematoma puncture
Neuroendoscopic hematoma removal
Surgical methods-Cranial hematoma removal
Open cranial hematoma removal: It is the most clinically performed surgical procedure and the most traditional one.
Advantages.
1.Direct vision: complete removal of hematoma and reliable hemostasis
2.Complete decompression: decompression with bone flap is feasible in case of brain herniation before surgery. Hematoma removal + decompression of bone flap
Disadvantages.
1.Requiring general anesthesia.
2.Long operation time.
3.Large trauma.
4. Intraoperative blood loss.
The application of this procedure is limited by the excessive strain on the brain tissue and the heavy postoperative edema reaction, which affects the patient’s postoperative recovery and the high operative mortality rate.
Scope of application.
1.Patients who have not deep bleeding site, large bleeding volume, obvious midline shift, and brain herniation formation but for a short period of time.
2.Patients with good general condition, no serious dysfunction of heart, lungs, kidneys and other important organs, who can tolerate the operation.
This method is also recommended for cerebellar hemorrhage to achieve rapid decompression.
Small bone window hematoma removal
According to CT or MR I, the projection position of the hematoma on the skull surface and the drilling site are determined, and the hematoma is removed under the microscope with a bone window diameter of 2.5-3 cm.
Advantages: 1. relatively shorten the operation time; 2. less intraoperative bleeding; 3. less surgical trauma.
Scope of application
1, mostly used for subcortical or nucleus accumbens hemorrhage which is less severe and the bleeding volume is not too large.
2, not suitable for patients with obvious midline shift and large hematoma volume.
Stereotactic hematoma removal
Stereotactic instrument
Direct localization of the target point with the help of CT and MRI guidance
Tube placement and drainage + urokinase hemolysis
Advantages: 1. precise puncture localization; 2. deep hematoma removal; 3. little injury.
Disadvantages.
1, requires special equipment, more complicated operation, longer operation time.
2, not applicable to patients with intracranial hypertension requiring urgent treatment.
3.Higher cost.
4. Risk factors such as respiratory distress and elevated blood pressure caused by head flexion during positioning scanning after installation of a stereotactic head frame.
Minimally invasive placement of hematoma puncture
Stereotactic localization method for intracerebral hematoma
Advantages: 1) simple and accurate localization; 2) easy operation with local anesthesia, and can be performed at the bedside in emergency situations; 3) less trauma, shorter operation time, and faster recovery; 4) low cost; 5) wide range of indications.
Disadvantages.
1, cannot clear the hematoma at one time, and the decompression effect is sometimes unsatisfactory.
2.The need for multiple injections of fibrinolytic drugs.
3, the possibility of re-bleeding under non-direct vision operation.
Neuroendoscopic hematoma removal
Advantages: 1, direct vision; 2, simultaneous flushing and suction; 3, supporting hemostatic techniques; 4, little damage.
Disadvantages.
1, Narrow field of view, difficult to observe the whole picture of the hematoma, resulting in incomplete removal of the hematoma.
2.It is not easy to control large bleeding, and it is difficult to deal with large hematoma.
Only Auer reported the use of endoscopy to remove intracerebral hematoma and achieved good results. However, at present, endoscopy is only used as an auxiliary device for cerebral hemorrhage removal at home and abroad, and this technology is still in the exploration and research stage.
The choice of surgical method is determined by a combination of patient factors: state of consciousness, site of hemorrhage, amount of hemorrhage, time from onset to medical consultation, presence of secondary damage: e.g., acute obstructive hydrocephalus, brain herniation
Outlook: The problem of hypertensive cerebral hemorrhage is far from being solved, and the incidence tends to increase with the aging of society.
Early surgery, removal of as much hematoma as possible, minimal damage to brain tissue, and treatment of postoperative complications are the future directions of surgical development.
(9) Outlook
Open hematoma removal with the application of microscopic techniques and new materials will still play an important role in the process of rescuing patients with heavy bleeding and brain herniation. The application of microinvasive techniques as a highly promising treatment method for H ICH follows this developmental trend, but greater breakthroughs in promoting hematoma liquefaction are needed to truly demonstrate the superiority of microinvasive surgery and to open up new horizons for standardized treatment of cerebral hemorrhage as evidenced by randomized controlled clinical studies of large numbers of cases.