Case: A middle-aged male with a sudden onset of unconsciousness for 5 hours with vomiting and limb convulsions, vomiting in the form of jets, vomit was stomach contents, blood pressure measured 240/120 mmHg, the patient’s condition gradually worsened and he developed respiratory distress and was admitted to the hospital emergency room by 120. The patient had a 4-year history of hypertension and did not regularly monitor his blood pressure or take antihypertensive medication. On admission, body temperature was 41°C, respiration was 122 breaths/min, blood pressure was 140/82 mmHg, confusion, shortness of breath, lip cyanosis, passive position, and uncooperative on physical examination. Bilateral pupils were equally large and round, 1.0 mm in diameter (pupil narrowing), and direct or indirect light reflexes were retarded. The limb muscle strength examination was uncooperative, the limb muscle tone was not high, the deep and superficial reflexes disappeared, and the Bartholomew’s sign, Brønsted’s sign, and Gram’s sign were negative.
What disease did this person have that made his condition so severe? A cranial CT examination suggested a brainstem hemorrhage of about 8 ml.
First, let’s understand what is the brainstem and what is its role in the human body?
The brainstem is a part of the brain, located below the brain, and the medulla oblongata part of the brainstem is connected to the spinal cord. It is irregularly columnar in shape. The brainstem is composed of the medulla oblongata, pons and midbrain. The function of the brainstem is mainly to maintain the life of an individual, including important physiological functions such as heartbeat, respiration, digestion, body temperature, and sleep.
So, what is brainstem hemorrhage? What are the risks of brainstem hemorrhage?
Brain hemorrhage refers to primary non-traumatic intracerebral parenchymal and intraventricular hemorrhage, and hemorrhage occurring in the brainstem is called brainstem hemorrhage. The mortality rate of brainstem hemorrhage is very high. If the amount of brainstem hemorrhage is less than 3ml, the mortality rate is about 70%; if the amount of hemorrhage is more than 5, the mortality rate is about 90%; among them, the mortality rate is 100% if the amount of hemorrhage is more than 10ml.
So, what causes brainstem hemorrhage?
Hypertension complicated by atherosclerosis: the most common cause of brainstem hemorrhage; intracranial aneurysm: mainly congenital aneurysm; cerebral arteriovenous malformation: abnormal development of blood vessel wall, easy to bleed; common triggers: such as irregular use of anti-hypertensive drugs, emotional excitement, excessive fatigue, lack of sleep or irregularity, chronic respiratory infection, chronic constipation, etc. can also cause a sudden rise in cerebral blood pressure, leading to the occurrence of brainstem hemorrhage.
What are the clinical manifestations of brainstem hemorrhage?
It often manifests as sudden onset, severe headache, vomiting, and the patient appears coma early and heavily, often within seconds to minutes. When the thermoregulatory center is damaged, central hyperthermia may occur; when the respiratory center is affected, abnormal respiration may occur. Signs such as tetraplegia, pinpoint pupils, and denervation tonicity may also be present. Let’s make a comparison table with the above cases to see the manifestations of brainstem hemorrhage.
How to treat brainstem hemorrhage?
Principles of treatment for brainstem hemorrhage: adjust blood pressure, prevent further bleeding, lower cranial pressure, enhance nursing care, and prevent and treat complications.
1.Maintain vital functions: ventilator-assisted breathing, phlegmolytic drugs to ensure the smooth flow of airways, physical cooling, etc.
2.Lower intracranial pressure: mannitol, tachyphylaxis, glycerol fructose, dexamethasone, dehydration to lower cranial pressure.
If the systolic blood pressure is still higher than 200 mmHg or diastolic blood pressure is higher than 100 mmHg after dehydration and lowering of cranial pressure, mildly acting antihypertensive drugs or oral antihypertensive drugs should also be used. A sudden drop in blood pressure during the acute phase indicates a serious condition, and antihypertensive drugs should be given to ensure adequate cerebral blood supply.
4.Hemostatic drugs: Most people think that hemostatic drugs are not effective for brainstem hemorrhage, but they can still be used if there is a combination of upper gastrointestinal bleeding or coagulation disorder. In case of gastrointestinal bleeding, hemostatic drugs can also be given via nasal feeding tube or orally.
5. Prevention of stress ulcers: Stress ulcers are likely to occur in the acute phase in elderly patients, and routine application of intravenous anti-ulcer drugs (H2 receptor antagonists) is recommended; in patients with gastrointestinal bleeding, ice-saline gastric lavage and local application of hemostatic drugs (such as oral or nasal Yunnan Baiyao, thrombin, etc.) should be performed; in cases of heavy bleeding, transfusion of fresh whole blood or red blood cell component transfusion is required if necessary.
6, prevention and control of pulmonary infections: patients with impaired consciousness are prone to respiratory and urinary tract infections, which are important causes of exacerbation of the disease. Patients in proper position, frequent turning and back patting and prevention of misaspiration are important measures to prevent pneumonia. Treatment of pneumonia mainly includes respiratory support (such as oxygen therapy) and antibiotic therapy.
How to prevent brainstem hemorrhage?
1. Stabilize blood pressure
The most common cause of brainstem hemorrhage is high blood pressure. Controlling blood pressure is equivalent to preventing a large part of the possibility of brainstem hemorrhage.
2.Stop smoking and limit alcohol
Alcohol and cigarettes can cause vasoconstriction, heart rate increase, blood pressure rise and accelerate atherosclerosis. People with hypertension, coronary heart disease and cerebral arteriosclerosis should quit smoking and limit alcohol.
3.Diet regulation
Diet should pay attention to low fat, low salt, low sugar. Eat less animal brains, offal, more vegetables, fruits, soy products, with the right amount of lean meat, fish, egg products.
4, pay attention to the regularity of life
Develop good living habits, work and rest on time, ensure enough sleep and rest time, avoid strain, physical and mental labor should not be too strenuous, overload work can trigger brainstem hemorrhage, participate in moderate and appropriate cultural and sports activities.
5.Adjust emotion
Keep optimistic emotions, avoid excessive excitement or tension, hypertension patients in tension vasoconstriction response than normal people lasting, mental tension, autonomic activity can cause a sustained increase in hypertension.
6.Prevent constipation
Dry stool, defecation force, not only the abdominal pressure rises, blood pressure and intracranial pressure also rises at the same time, it is easy to make the fragile small blood vessels rupture and cause brainstem hemorrhage.
7, pay attention to the symptoms around the warning
Although the onset of brainstem hemorrhage is mostly sudden, some patients will have some aura symptoms of varying severity in the hours or days before the onset, such as sudden headache aggravation or change from intermittent to persistent in patients with high blood pressure; sudden dizziness or obvious aggravation of the original dizziness; sudden transient numbness, weakness or lack of flexibility in one limb or head and tongue; or sudden leakage of air from the corners of the mouth, hard tongue, inability to bite or spit out words; or sudden persistent blood pressure. If there is a sudden increase in blood pressure and it does not drop, you should seek medical attention as soon as possible.