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.
Differential diagnosis
①It should be differentiated from cerebral infarction when CT examination is not available.
②For those with sudden onset, rapid coma and focal signs are not obvious, attention should be paid to differentiate with systemic poisoning (alcohol, drugs, carbon monoxide) and metabolic diseases (diabetes, hypoglycemia, hepatic coma, uremia) that cause coma, medical history and relevant laboratory tests can provide diagnostic clues, and there is no hemorrhagic change in cranial CT;
③Traumatic intracranial hematoma mostly has a history of trauma, and the hematoma can be detected by cranial CT;
④If the hemorrhage is located in the nucleus accumbens, 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 disease and anticoagulation, 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 during the chronic course.
Treatment
To save the life of the patient, reduce the degree of neurological disability and reduce the recurrence rate, active and reasonable treatment should be taken.
1.Medical treatment
(1) Keep quiet, rest in bed and reduce visits. Closely observe body temperature, pulse, respiration and blood pressure and other vital signs, and pay attention to pupil and consciousness changes. Keep the respiratory tract unobstructed, clear respiratory 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 or 48 hours and then place a gastric tube as appropriate.
(2) Water-electrolyte balance and nutrition, daily fluid intake after the disease can be calculated according to the amount of urine ten 500m1, such as 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. Take care to prevent hyponatremia, which may aggravate cerebral edema. Supplement sodium with 50 or 70 mmol/L, potassium with 40-50 mmol/L and sugar with 13.5 or 18 g daily.
(3) Control cerebral edema and reduce intracranial pressure. Cerebral edema reaches a peak in about 48h after cerebral hemorrhage and gradually decreases after 3 or 5d, which may last for 2 or 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.
The following are available
Mannitol can increase the plasma osmolality in a short time, forming an osmotic pressure difference between blood and brain tissue. The course of treatment is 7 or 10 d; if there are signs of cerebral herniation, rapid pressure can be pushed through the vein or carotid artery, but symptomatic 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;
②Diuretics, tachyphylaxis is more commonly used, often combined with mannitol to enhance the effect of dehydration, 40mg each time, 2 or 4 times a day, intravenous injection;
③glycerol should be used during the improvement period of mild symptoms or severe disease, 10% compound glycerol solution 500m1, once daily, intravenous drip, 3 or 6 hours to finish; dehydration, lowering cranial pressure effect than mannitol and slow, too much or too fast infusion is prone to hemolysis;
④10% serum albumin, 50 or 100m1, once daily, intravenous, more suitable for patients with hypoproteinemia, can improve the colloid osmotic pressure, the effect is longer lasting;
⑤ Dexamethasone, can reduce capillary permeability, maintain the blood-brain barrier function, 12 or 36 hours after the drug to show anti-brain edema effect; because of easy to complicate infection or promote stress ulcers in the upper gastrointestinal tract, affect the control of blood pressure and blood sugar, so it is not advocated for routine use; for critical patients can be applied early for a short time, 10 or 20mg/d, intravenous drip.
(4) Control hypertension, cerebral hemorrhage after the increase in blood pressure is to maintain a relatively stable cerebral blood flow (CBF) in the case of ICP increased cerebrovascular auto-regulatory response, when ICP decreases blood pressure will also fall, so usually do not use antihypertensive drugs, especially the injection of strong antihypertensive drugs such as blood pressure; should be determined according to the patient’s age, the presence of hypertension before the disease, the post-disease blood pressure situation, such as the optimal blood pressure level. Systolic blood pressure of 180 or 230 mmHg or diastolic blood pressure of 105 or 140 mmHg should be treated with oral antihypertensive drugs such as captopril and betalac; systolic blood pressure 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 the disease in patients with mild disease, such as 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 and other easy to combine urinary tract infection, can be given prophylactic antibiotic treatment, according to experience or sputum culture, urine culture and drug sensitivity test results of the choice of antibiotics; at the same time to keep the airway open, 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.
Stress ulcers can cause gastrointestinal bleeding. For prevention, H2 receptor blockers, such as methocarbamol 0.2~0.4g/d, intravenous; ranitidine 150mg orally, 1 or 2 times daily; Loxacol 20 or 40mg orally or intravenously daily; omeprazole 200mg orally, 3 times daily; and aluminum hydroxide gel 40 or 60m1 orally, 4 times daily; once bleeding should be treated according to the upper gastrointestinal bleeding Once the bleeding is treated, hemostatic drugs 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 medical treatment is not effective, hemostasis can be stopped under direct endoscopy; asphyxia should be prevented when vomiting blood, and fluid or blood transfusion should be given to maintain blood volume;
(③Anti-diuretic hormone secretion abnormality syndrome, also known as dilutional hyponatremia, can occur in about 10% of ICH patients, because of increased sodium excretion via urine, blood sodium decreases, aggravating cerebral edema, water intake should be limited to 800~1000ml/d, sodium supplementation 9 or 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, without long-term treatment;
⑤ Central hyperthermia, it is advisable to first physical cooling, if the effect is not good, dopaminergic agonists such as bromocriptine 3, 75mg/d, gradually increase the amount to 7.5~15.0mg/d, divided into doses; also available nifedipine 0.8 or 2.5mg/kg, intramuscular or intravenous administration, 6~12 hours once, after remission with 100mg, 2 times/d;
(6) Deep vein thrombosis of lower limbs, manifesting progressive swelling and stiffness of limbs, can be prevented by regular turning, passive activity or elevation of paralyzed limbs; once it occurs, limb venous hemogram should be performed and common heparin 100mg intravenous drip once daily or low molecular heparin 4000IU subcutaneous injection twice daily.
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 or 24 h 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, kidney, etc.
①Patients with cerebral hemorrhage gradually develop signs of increased intracranial pressure with brainstem compression, such as slow heart rate, elevated blood pressure, slowed respiratory rhythm, decreased level of consciousness, or articulatory nerve palsy;
(2) Hematoma of cerebellar hemisphere hemorrhage >15ml, hematoma of earthworm >6m1, hematoma breaking into the fourth ventricle or brain pool pressure disappears, symptoms of brainstem pressure or signs of acute obstructive hydrocephalus appear;
(iii) obstructive hydrocephalus due to ventricular hemorrhage;
④Young patients with hemorrhage in the lobes or nucleus accumbens to a large amount (>30ml) 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
①Craniotomy for hematoma removal;
②Borehole enlargement of the bone window for hematoma removal;
③Tapered hole aspiration of hematoma;
④Stereotactic hematoma arch [flow operation;
⑤Ventricular 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 the progress is stopped, rehabilitation treatment is appropriate as early as possible. Early rehabilitation will be beneficial to restore the neurological function of the patient and improve the quality of life. The patient should be given timely medication and psychological support for possible depression, such as fluoxetine 10 or 20mg orally, once a day.
4.Special treatment
① Non-hypertensive cerebral hemorrhage, such as abnormal coagulation function can be corrected by fresh frozen plasma and vitamin K or intravenous injection of fisetin; Thrombolytic treatment of concurrent cerebral hemorrhage can be treated with fisetin and 6 or aminohexanoic acid; Hemophilia-induced cerebral hemorrhage can be treated with the lack of coagulation factors or fresh plasma; Leukemia, aplastic anemia and other patients with abnormal platelet function should be imported platelets; Aspirin, thi Anti-platelet drugs such as aspirin, clopidine 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 control of rebleeding, cerebral hemorrhage reoccurrence rate is about 10%, adjusting blood pressure is the most critical.
④Unstable cerebral hemorrhage, can be due to high blood pressure, long-term heavy drinking or related to inappropriate moving after the onset; CT shows hematoma edge irregularity, uneven density, irregular shape, the condition can continue to aggravate or deteriorate rapidly, or once stable and then suddenly aggravated, should be closely monitored, timely review of cranial CT, and strengthen therapeutic measures.
IV. Prognosis
Cerebral 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, with a rate of 35% or 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 herniation are the main causes of death. The prognosis is related to the amount and location of hemorrhage, etiology and systemic 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.