It is the most serious type of acute cerebrovascular disease, and is one of the most lethal diseases among middle-aged and elderly people.
Middle-aged and elderly people are the main group of people who suffer from cerebral hemorrhage, with 40-70 years old being the most important age of onset. The causes of cerebral hemorrhage are mainly related to cerebral vascular lesions and sclerosis. The cause of cerebral hemorrhage is mainly related to the lesion and hardening of cerebral blood vessels. The lesion of blood vessels is closely related to hyperlipidemia, diabetes, hypertension, aging of blood vessels and smoking. The commonly referred to cerebral hemorrhage refers to spontaneous primary cerebral hemorrhage. Patients often have a sudden onset due to emotional excitement and effortful exertion, manifesting as aphasia, hemiparesis, or in severe cases, unconsciousness, and more than half of the patients are accompanied by headache and vomiting.
The main cause of cerebral hemorrhage is long-term hypertension and arteriosclerosis. The vast majority of patients have a significant increase in blood pressure at the time of onset, leading to blood vessel rupture and causing cerebral hemorrhage.
Cerebral hemorrhage is a non-traumatic bleeding in the brain parenchyma. Most of them are caused by the rupture of small cerebral artery lesions associated with hypertension when the blood pressure rises suddenly, called hypertensive cerebral hemorrhage.
Aura of cerebral hemorrhage
In contrast, cerebral hemorrhage is usually more acute, with an onset time of only a few minutes or hours, but there is a gradual progression of cerebral hemorrhage. In the early stages of the disease, some abnormalities are more or less present, i.e., some precursory manifestations. In 50% of patients with cerebral hemorrhage, aura symptoms are present. The risk of cerebral hemorrhage is high in the first year after the onset of aura, especially in the first two months. Once these aura manifestations appear, it is a sign that a brain hemorrhage is about to occur or is already in the prodromal stage of brain hemorrhage. At this time, if you can observe carefully, you can detect the abnormalities in time and go to the hospital for treatment in a race against time, so as to control the development of the disease and avoid serious consequences.
Common precursor symptoms of cerebral hemorrhage are.
①Suddenly feeling numbness, weakness and difficulty in moving one side of the body, dropping objects in the hand, distorted mouth, salivation and unstable walking.
②Suddenly unable to speak when talking with others, or slurring words, or not understanding others’ words.
③Temporary blurred vision, which may return to normal later on its own, or blindness may occur.
④Sudden dizziness, rotation of the surrounding scenery, unsteadiness or even fainting on the ground. These manifestations may appear once briefly, or they may appear repeatedly or worsen gradually.
When the above aura symptoms appear, patients should pay great attention to them, but should not be overly nervous and panic. The patient should be calm and avoid aggravation due to fluctuation of blood pressure. The patient should be sent to the hospital as soon as possible, and tell the doctor in detail about the aura manifestations that have appeared, so that the diagnosis can be clarified and treated in time.
Clinical manifestations and diagnosis of cerebral hemorrhage
I. Medical history and symptoms.
Most of them have a history of hypertension, which is common in middle-aged and elderly people, with more onset in the cold season. Most of them start in the active state, with sudden onset of severe headache with vomiting, mostly with impaired consciousness, high blood pressure at the onset, and focal neurological symptoms related to the site of bleeding and the amount of bleeding.
Second, physical examination revealed that.
1, there are varying degrees of impaired consciousness, early more blood pressure is significantly elevated, in severe cases the pulse flood is slow, respiration is deep and slow, often accompanied by central hyperthermia, when the condition deteriorates it presents central respiratory and circulatory failure, pupils are irregularly shaped, bilaterally narrowed or dilated, bilaterally unequal in size, and light response is dull or absent. Positive signs of meningeal stimulation, retinal arteriosclerosis and retinal hemorrhage, occasional optic papilloedema, upper gastrointestinal bleeding, cardiac arrhythmia, pulmonary edema, etc. are seen in the fundus.
2.Limited localization signs.
(1) Shell nucleus type hemorrhage mainly has triple hemianopia signs (hemiplegia hemianopsia hemianopsia hemianopsia hemianopsia sensory impairment) both eyes are staring in the same direction, the left hemisphere may have aphasia.
(ii) thalamic type may have hemiparesis, hemianopsia, hemianesthesia, vertical gaze paralysis and convergence in both eyes, and pupil narrowing.
(③) Lobar type has mild impairment of consciousness, more pronounced convulsive seizures and meningeal irritation signs, and focal signs vary depending on the damaged lobes.
(iv) Pontocerebellar type coma with deep pupils and small hyperthermia presenting as decerebrate tonicity or tetraplegia (in heavy cases) in light cases with crossed paralysis and sensory impairment oculomotor disorders (extraocular muscle paralysis with isotropic gaze paralysis inter-nuclear oculomotor paralysis);
⑤ cerebellar type for vertigo nystagmus ataxia (lighter) in heavy cases coma flaccid limbs, etc.
(6) ventricular type for pinpoint pupil coma deep hyperthermia and detrusor ankylosis.
Treatment
1.Treatment principle, reduce intracranial pressure and control cerebral edema to prevent brain herniation formation, reduce the increased blood pressure to prevent further bleeding.
2.Conventional treatment
General treatment.
① Keep quiet, absolute bed rest, should be resuscitated locally, should not be transported long distance and moved too much to avoid aggravating bleeding.
② Keep the respiratory tract unobstructed and suck out oral secretions or vomit at any time.
iii. control cerebral edema and reduce intracranial pressure.
Fourth, control hypertension, reduce the increased blood pressure is an important measure to prevent further bleeding, but should not lower the blood pressure too low, to prevent insufficient blood supply.
It is generally appropriate to maintain it at 20.0~21.3/12.0~13.3kpa (150~160/90~100mmhg).
V. Hemostatic and coagulant drugs are not effective for cerebral hemorrhage, but can still be used if combined with gastrointestinal bleeding or if there is a coagulation disorder.
vi. prevention and treatment of complications: critically ill patients should especially strengthen basic care, gently change position at regular intervals, pay attention to dry and clean skin, prevent decubitus ulcers and pulmonary infections, paralyzed limbs should be kept in a functional position, massage and passive movement to prevent joint contractures.
Surgical treatment ：
In addition to drug treatment, surgery can be considered in some cases of cerebral hemorrhage.
There is no uniform standard regarding the indications for surgical treatment. In general, if the treatment principle is selected by the amount of bleeding, surgery should be performed for bleeding greater than 30 ml in the shell nucleus, 14 ml in the thalamus, 15 ml in the cerebellar hemispheres, and 6 ml in the cerebellar earth.
If the treatment principle is selected according to the extent of hemorrhage in CT, surgery should be considered if the shell nucleus hemorrhage develops into the posterior limb of the internal capsule with or without breaking into the ventricle, if the shell nucleus hemorrhage develops into the anterior and posterior limbs of the internal capsule, if the thalamic hemorrhage is greater than 15 ml, if it involves the thalamus or the lower part of the thalamus, and if it breaks into the ventricle with or without breaking into the ventricle. If the patient is in a coma, shallow coma without brain herniation or brain herniation, the patient should be considered for surgery. If the patient is in deep coma, near death, respiratory arrest, or bilateral pupil dilatation, surgery should be deferred if one of these conditions is present. The surgical method for hypertensive cerebral hemorrhage should be decided according to the patient’s bleeding volume, bleeding site, time from surgery to bleeding, the patient’s age and general condition, and the experience of the surgeon. The principle of individualization also applies to cerebral hemorrhage, and each patient should be analyzed specifically and considered comprehensively to make decisions. The following surgical methods are commonly used to remove hematomas.
(1) Neuroendoscopic treatment technique: A small hole is drilled in the skull and a cranial endoscope is fed in to reach the hematoma site directly. Under the guidance of electronic monitoring equipment, the channel on the catheter is used to administer drugs directly at the bleeding point to stop the bleeding while cleaning and sucking out the residual clot. It has the advantages of short operation time and small trauma, and avoids the possible sequelae of craniotomy with massive exposure, incision and pulling of brain tissues, which helps the patient recover quickly.
(2) Minimally invasive tube placement and drainage for hypertensive cerebral hemorrhage: After accurate localization of the site of cerebral hemorrhage, only a small hole of 5cm×2.5cm is made in the patient’s skull or a direct minimally invasive directional cone skull is established to access the target point of intracranial hematoma, and a soft silicone tube is thus placed at the site of hemorrhage to attract the hematoma, and fibrinolytic drugs are repeatedly injected after surgery to dissolve the blood clot and flow out from the placed silicone tube. This significantly shortens the time than conservative treatment of intracerebral hematoma and helps the patient recover.
(3) Open cranial hematoma removal: It is a traditional operation, but for critically ill patients with large hematoma or brain herniation, open cranial surgery to completely remove the hematoma and stop the hemorrhage under direct vision, and parallel decompression is still the best operation method, and the application of microsurgery technology in recent years can make the operation more safe and delicate.
(4) Stereotactic aspiration: In recent years, stereotactic technology is used to precisely place the catheter into the hematoma cavity, and the hematoma is broken up by the hematoma fragmenter and then rinsed out, and the residual hematoma is discharged after the clot is dissolved by injecting thrombolytic drugs through the catheter left in the hematoma cavity.
Chinese medicine, acupuncture, and massage therapy are used in conjunction with treatment, which has certain effect on treatment and recovery.
Complications of cerebral hemorrhage
1. Pulmonary infection Pulmonary infection is one of the main complications and one of the main causes of death in people with cerebral hemorrhage. Within 3-5 days after cerebral hemorrhage, comatose patients are often combined with pulmonary infections.
2. Upper gastrointestinal bleeding is one of the serious complications of cerebrovascular disease, namely stress ulcers. Cerebral hemorrhage combined with upper gastrointestinal hemorrhage is predominantly of mixed type and medial capsule type, accounting for 49% and 36%, respectively. The mechanism of occurrence is due to lesions in the inferior optic thalamus and brainstem, which are now thought to be related to the anterior and posterior suboptic thalamus, the gray-white nodes and the vagal nucleus within the medulla oblongata. The autonomic center is in the inferior optic thalamus, but its higher centers are in the frontal orbital surface, hippocampal gyrus and limbic system. The mechanism of gastrointestinal hemorrhage is related to primary or secondary lesions in the above mentioned areas.
Decubitus ulcers are mainly a series of manifestations of ischemia and necrosis due to prolonged compression of the local skin and tissues as a result of the long-term non-change of body position. In patients with cerebrovascular disease, because of the high number of elderly patients, limb paralysis, long-term bed rest, and inconvenient activities, it is easy for the bone bulge and other parts of the compression, so that local tissue ischemia and hypoxia.
4, common complications after surgery for hypertensive cerebral hemorrhage pulmonary infection, rebleeding, gastrointestinal stress ulcers, renal failure and multiple organ failure (MOF), etc.