Cerebral hemorrhage, commonly known as cerebral hemorrhage, is a kind of “stroke” and a common serious brain complication in middle-aged and elderly patients with hypertension. The most common causes are hypertension, cerebral atherosclerosis, intracranial vascular malformation, etc. It is often triggered by exertion, emotional excitement and other factors, so most of the sudden onset in the activity. It is one of the fatal diseases in middle-aged and elderly people because of its rapid onset, dangerous condition and high mortality rate.
Causes
As the name implies, the most common cause of cerebral hemorrhage is hypertension, which is one of the most serious and highest-grade complications of hypertension and can cause death within a short period of time with extremely serious symptoms, even affecting basic physiological activities such as breathing and heartbeat within a short period of time. Taking into account all other causative factors, it is important to emphasize the point that hypertension must be effectively controlled in order to effectively avoid hypertensive cerebral hemorrhage. Based on the long-term effects of hypertension, any factor that can induce a short-term increase in blood pressure can lead to the occurrence of hypertensive cerebral hemorrhage. There are many factors that can induce a sudden increase in blood pressure in daily life, and here are some simple examples.
(1) External factors.
Climate change, clinically found that the occurrence of cerebrovascular disease is particularly common during seasonal changes, such as the junction of spring and summer, autumn and winter seasons, modern medicine believes that seasonal changes and changes in external temperature can affect the normal metabolism of human neuroendocrine, change the blood viscosity, plasma fibrin, adrenaline are elevated, capillary spasmodic contraction and increased brittleness. The intracranial blood vessels cannot adapt to such a more obvious change in a short period of time, that is, there are fluctuations in blood pressure, which eventually leads to the occurrence of cerebral hemorrhage.
(2) Emotional changes.
Emotional changes are another important trigger of cerebral hemorrhage, including extreme sadness, excitement, fear, etc. We always find that most patients with cerebral hemorrhage have a history of emotional agitation before the onset of the disease, and there has even been a study done to confirm that nearly 30% of the patients in the clinic are angry and emotionally agitated leading to cerebral hemorrhage. The reason for this is mainly due to the sympathetic excitement, rapid heartbeat and sudden increase in blood pressure when the mood changes for a short period of time, the original fragile blood vessel rupture.
(3) Bad lifestyle habits.
Smoking has more serious health effects on the human body is recognized by the World Health Organization, long-term smoking can make the body’s vascular fragility increased, the ability to withstand fluctuations in blood pressure is prone to cerebral vascular rupture. And long-term alcohol consumption can cause vasoconstriction diastolic adjustment disorders, and vascular endothelial damage, intravascular lipid deposition, making the vascular conditions become poor, prone to cerebral hemorrhage. In addition, frequent overexertion and lack of physical exercise can also increase blood viscosity and destroy vascular conditions, leading to cerebral hemorrhage.
The above is only a list of the more common triggers in our clinic, not all patients must have these triggers, some patients can also occur brain hemorrhage in a quiet state due to the role of long-term various underlying diseases, the pathological mechanism of the occurrence of brain hemorrhage is more complex, especially patients who often have the above triggers need to be cautious to prevent the occurrence of serious complications.
Disease classification
The classification of cerebral hemorrhage determines the clinical symptoms of the patient and also indicates the prognosis of the disease, which has a more important significance for the treatment and rehabilitation of the patient. There are many clinical classification methods, and when diagnosing the disease, it is necessary to consider various classification methods to clarify the nature of the disease. Cerebral hemorrhage is classified according to the time of onset: hyperacute, acute and subacute, and according to the severity of the disease is divided into mild, moderate and heavy. The clinical classification is mostly based on the site of hemorrhage, which is described as follows.
(1) Bleeding in the basal ganglia region.
The basal ganglia area is the most common site of cerebral hemorrhage, and the ruptured hematoma of the doublestem artery is located in the basal ganglia. Basal ganglia hemorrhage can be subdivided into: shell nucleus hemorrhage, thalamic hemorrhage, caudate nucleus head hemorrhage, etc.
The clinical manifestations are related to the site of hematoma and the amount of hematoma. The common symptoms in case of large amount of hemorrhage are hemiparesis caused by damage to the internal capsule, bilateral eye gaze to the side of the lesion, and hemianesthesia. When the hemorrhage is large, it affects the circulation of cerebrospinal fluid and compresses the brain tissue, resulting in coma, respiratory and heartbeat effects for a short time, and even death within a short time.
The characteristics of thalamic hemorrhage are similar to those of thalamic hemorrhage, such as paraplegia and sensory impairment, but also mental disorders, such as depression and apathy, and dementia and memory loss, etc. A large amount of hemorrhage can be life-threatening for a short time. Due to the location near the third ventricle, symptoms of thalamic hemorrhage tend to recur, and symptoms such as persistent and persistent hyperthermia may also occur.
(3) Hemorrhage in the caudate nucleus: It is rare, the bleeding volume is often small, and it often breaks into the ventricles, showing symptoms of acute hydrocephalus such as nausea, vomiting, headache, etc. Typical symptoms of hemiplegia of the limbs do not appear, and the clinical manifestations may be similar to those of subarachnoid hemorrhage.
(2) Lobar hemorrhage.
The incidence is relatively small, accounting for about 5% to 10% of cerebral hemorrhage, and is generally common in patients with combined intracranial vascular malformation, hematologic disease, and smog. The clinical manifestations can include limb deviation, seizures, aphasia, headache, urinary incontinence, visual field defects, etc.
(3) Cerebral bridge hemorrhage.
Cerebral bridge hemorrhage accounts for about 10% of cerebral hemorrhage, the cerebral bridge is a more important life center, this type of hemorrhage is quite critical, hemorrhage greater than 5 ml can appear coma, tetraplegia, respiratory distress and other symptoms, but also acute stress ulcers, central intractable hyperthermia, etc., most patients soon after the onset of multi-organ failure, often within 48 hours after the onset of death, cerebral bridge hemorrhage Because of the extreme danger, the treatment rate and cure rate are low, and it is a kind of critical cerebral hemorrhage.
(4) Cerebellar hemorrhage.
Cerebellar hemorrhage is located in the posterior cranial fossa, and bleeding greater than 10 ml is a surgical pointer. Cerebellar hemorrhage accounts for about 10% of cerebral hemorrhage. After the onset, cerebellar function may be impaired: vertigo, ataxia, frequent vomiting, severe pain in the posterior occipital region, and generally no symptoms of hemiplegia of the limbs, and cerebellar hemorrhage may affect the respiratory function when the cerebellar bridge is compressed. After hemorrhage in the cerebellar earth (the central part of the cerebellar hemispheres bilaterally), the hematoma may compress the four ventricles and affect the cerebrospinal fluid circulation, resulting in acute hydrocephalus within a short period of time, which requires surgery if necessary.
(5) Ventricular hemorrhage.
Primary ventricular hemorrhage is less common and is more often seen in peripheral sites where hemorrhage breaks into the ventricles. The symptoms of primary ventricular hemorrhage are more obvious, such as sudden onset of headache, vomiting, neck tonicity, etc. A large amount of hemorrhage can quickly enter coma symptoms.
According to the clinical manifestations after hemorrhage, neurosurgery clinically classifies cerebral hemorrhage into five grades, which are used as reference for surgical indications.
Grade I: wakefulness or drowsiness with varying degrees of hemiparesis or aphasia.
Grade II: drowsiness or haziness with varying degrees of hemiparesis or aphasia
Grade III: shallow coma with hemiparesis and equilibrium pupils.
Grade IV: coma with hemiparesis, equal or unequal size
Grade V: deep coma, decerebrate tonicity or floppy limbs, and unilateral or bilateral dilated pupils.
Differential diagnosis
The onset of cerebral hemorrhage is more critical, and some of the symptoms are very similar to cerebral infarction. Before the popularization of CT, the misdiagnosis rate of cerebral infarction and cerebral hemorrhage was high, but with the improvement of the current level of treatment, the diagnosis is basically clear after CT examination, but careful and cautious differential diagnosis is still required.
(1) Differentiation from other cerebrovascular diseases such as cerebral infarction and subarachnoid hemorrhage, the diagnosis is confirmed according to the pathogenesis, symptoms, signs and imaging examinations. Cerebral infarction is caused by ischemia of brain tissue, and the common cause is cerebral atherosclerosis. The onset of the disease is usually slow, with mild impairment of consciousness and slightly elevated blood pressure, which is seen as an intracerebral hypodense lesion on CT.
(2) Intracranial occupying lesions, craniocerebral trauma, meningitis and other diseases: diagnosis is made based on the degree of urgency of onset, history of trauma, other clinical manifestations such as fever and CT, MRI, cerebrospinal fluid and other examinations. Primary tumors in the brain may show symptoms similar to cerebral hemorrhage, such as headache, vomiting and limb symptoms, etc. Enhanced imaging may help to make the diagnosis.
(3) Other causes: Coma patients should be differentiated from carbon monoxide poisoning, hepatic coma, uremia, hypoglycemia and other causes of impaired consciousness. Mainly detailed history, physical signs and CT, cerebrospinal fluid and other examinations. Hematologic disorders such as leukemia, thrombocytopenic purpura, and aplastic anemia can present with intracranial hemorrhage, and careful examination is needed when these causes are suspected to rule out similar symptoms from other causes.
Treatment of disease
Treatment of hypertensive cerebral hemorrhage can be divided into conservative medical treatment and surgical treatment. Recent investigations have shown that early surgical removal of the hematoma can result in a significant reduction in morbidity and mortality.
Internal treatment
Patients with low bleeding volume, mild neurological impairment, or patients whose general condition is too poor to milk surgical treatment can choose conservative medical treatment. The principles of internal medicine treatment are: dehydration to lower cranial pressure, reduce cerebral edema, and adjust blood pressure; prevent rebleeding; reduce secondary damage caused by hematoma and promote neurological recovery; and prevent complications.
1. General treatment.
Quiet rest, generally bed rest for 2~4 weeks. Keep the airway unobstructed, prevent the back of the tongue, perform tracheotomy if necessary, and patients with impaired consciousness and decreased oxygen saturation should be given oxygen. Critically ill patients should be given cardiac monitoring and monitoring of body temperature, blood pressure, respiration and other vital signs.
2. Blood pressure control.
Patients with cerebral hemorrhage will have a reflex increase in blood pressure, while too high blood pressure will cause more bleeding, and too low blood pressure will affect the blood supply to healthy brain tissue, so for patients with cerebral hemorrhage, more effective antihypertensive drugs should be used to control blood pressure to the basal blood pressure level before the onset.
3. Control cerebral edema and reduce intracranial pressure.
Elevated intracranial pressure can cause more obvious symptoms such as nausea and vomiting in patients, and in serious cases, it can also cause brain herniation leading to life threatening. Therefore, reducing intracranial pressure to control cerebral edema is the general measure of cerebral hemorrhage treatment, early onset of dehydration with mannitol and auxiliary dehydration with furosemide, and at the same time, pay attention to monitoring the kidney function of patients, pay attention to review the blood electrolyte situation to prevent water-electrolyte disorders.
4, prevention of complications.
Antibiotics and drugs to reduce gastric acid secretion can be used prophylactically to prevent pulmonary infections and stress ulcers in the upper gastrointestinal tract. Early gastrointestinal decompression is feasible to observe the presence of stress ulcers, and to reduce abdominal distension caused by gastrointestinal paralysis and avoid aspiration pneumonia due to vomiting of gastric contents.