Spontaneous cerebral hemorrhage (hereinafter referred to as “cerebral hemorrhage”) is a non-trauma-induced bleeding in the brain parenchyma caused by spontaneous rupture of large and small arteries, veins and capillaries in the adult brain.
1. Classification
Spontaneous cerebral hemorrhage can be divided into primary and secondary cerebral hemorrhage according to the cause, primary cerebral hemorrhage is common, accounting for about 80% – 85%, mainly for hypertensive cerebral hemorrhage and amyloid angiopathy cerebral hemorrhage. Secondary cerebral hemorrhage mainly includes arteriovenous malformation, aneurysm, cavernous hemangioma, arteriovenous fistula, etc.
2.Diagnostic criteria
The diagnostic criteria for primary cerebral hemorrhage are
① A clear history of hypertension.
② Imaging examination suggesting typical bleeding sites, such as basal ganglia area, thalamus, ventricles, cerebellum, brainstem (in patients with hypertensive cerebral hemorrhage), and brain lobes (in patients with CAA).
③ Exclusion of coagulation disorders and hematologic disorders.
④ CTA/MRA/MRV/DSA examination to exclude other cerebrovascular pathologies (choose 1 – 2 examinations).
⑤ Ultra-early (within 72 hours) or late enhanced MRI to exclude brain tumor.
3.Pre-hospital emergency and emergency management
Pre-hospital emergency and emergency management are crucial to the prognosis. Attention should be paid to keep the patient in lateral position at all times during the transfer to reduce bumps. Upon arrival at the emergency department, CT examination of the head should be performed quickly to determine whether there is cerebral hemorrhage and the size of the hematoma for subsequent triage? Small to medium intracranial hematoma? Patients without obvious cranial hypertension can be temporarily treated conservatively; patients with large intracranial hematoma or with obstructive hydrocephalus; patients with severe cranial hypertension or even brain herniation should be immediately referred to neurosurgery for surgical treatment.
4.Main non-surgical treatment
The non-surgical treatment of cerebral hemorrhage includes intracranial hypertension treatment, blood pressure management, seizure control, hemostasis, application of anti-platelet drugs and prevention of deep vein thrombosis, temperature management, blood sugar management, nutritional support, neuroprotection, and complication prevention and treatment.
(1) Treatment of intracranial hypertension.
Commonly used anti-cranial pressure drugs include mannitol? Mannofructose? Human albumin? Diuretics, etc., especially mannitol is widely used, and the commonly used dose is 1–4g/kg・・d.
(2) Blood pressure management.
① In patients with cerebral hemorrhage with systolic blood pressure of 150–220 mmHg and no contraindications to acute antihypertensive therapy, reduction of systolic blood pressure to 140 mmHg in the acute phase is safe (Class I, Level A evidence) and effective in improving functional outcome (Class IIa, Level B evidence).
(ii) In patients with cerebral hemorrhage with systolic blood pressure >220 mmHg, intensive blood pressure lowering with continuous intravenous medication and frequent blood pressure monitoring is reasonable (Class IIb, Level C evidence)? However, in clinical practice it should be based on the length of the patient’s history of hypertension? basal blood pressure values? intracranial pressure status and blood pressure at admission to individualize the decision of blood pressure lowering target.
③ To prevent excessive blood pressure lowering leading to cerebral perfusion pressure deficiency, the blood pressure can be lowered by 15–20% daily based on the admission hypertension, and this distribution ladder method of blood pressure lowering is available for reference.
5.Surgical treatment
Bleeding in the basal ganglia area
(1) Indications for surgery: Emergency surgery may be considered for those with one of the following manifestations.
①Hernia of the temporal lobe hook gyrus.
(ii) Significant intracranial hypertension manifestation on imaging (midline structure displacement more than 5mm; ipsilateral lateral ventricular compression occlusion more than 1/2; ipsilateral cerebral pool cerebral sulcus blurred or disappeared.
(3) Actual measurement of intracranial pressure > 25 mmHg.
(2) Surgical procedure and method
Although the bone flap craniotomy is slightly more traumatic to the scalp and skull, it can completely remove the hematoma under direct vision, with reliable hemostasis and rapid decompression, and it can also decide whether to decompress the bone flap according to the patient’s condition and intracranial pressure changes during the operation.
The small bone window craniotomy is relatively simple and can remove the hematoma quickly, and the hemostasis under direct vision is also more satisfactory.
③Neuroendoscopic hematoma removal uses a combination of rigid mirror and stereotactic technique to remove the hematoma.
④Stereotactic cone cranial hematoma aspiration is performed by locating the hematoma site according to CT, using stereotactic head frame positioning or ruler positioning, and puncturing the hematoma under direct vision using disposable intracranial hematoma crushing puncture needle or common suction device and other instruments.
Thalamic hemorrhage
(1) Surgical indications: refer to cerebral hemorrhage in the basal ganglia.
(2) Surgical methods.
(1) Various hematoma removal procedures refer to basal ganglia cerebral hemorrhage.
External ventricular drainage is suitable for patients with thalamic hemorrhage breaking into the ventricle and small thalamic parenchymal hematoma, but with obstructive hydrocephalus and obvious intracranial hypertension, usually with external drainage of the frontal horn of the lateral ventricle.
(3) Surgical points and postoperative management refer to basal ganglia hemorrhage
Lobar hemorrhage
For patients with suspected amyloid angiopathy, special attention should be paid to intraoperative hemostasis.
Ventricular hemorrhage
(1) Indications for surgery and surgical methods.
①Small to moderate bleeding without obstructive hydrocephalus, which can be treated conservatively or with continuous external drainage of the lumbar pool.
(2) A large amount of bleeding, more than 50% of the lateral ventricle, combined with obstructive hydrocephalus? external drainage of the ventricular borehole.
(③) If the bleeding volume is large and exceeds 75% of the ventricle or complete ventricular cast, and the intracranial hypertension is obvious, external drainage of the ventricular borehole or craniotomy can be performed to remove intracerebral hematoma directly.
(2) The main points of surgery and postoperative treatment are the same as those for basal ganglia hemorrhage.
Contraindications to surgical treatment.
(1) Severe coagulation dysfunction.
(2) Those who are confirmed to be brain dead.