I. Etiology
The common cause is hypertension combined with fine arteriosclerosis, others include cerebrovascular malformation, aneurysm, blood disorders, vasculitis, aneurysmal stroke, etc. Excessive force, climate change, alcohol consumption, emotional excitement, overexertion, etc. are the triggering factors.
II. Clinical manifestations
1.Motor and speech disorders
Motor disorders are more common with hemiplegia; speech disorders are mainly manifested as aphasia and slurred speech.
2.Vomiting
Vomiting occurs in about half of the patients, which may be related to the increase of intracranial pressure, vertigo attack and blood stimulation of meninges during cerebral hemorrhage.
3.Disorders of consciousness
It manifests as drowsiness or coma, the degree of which is related to the site of brain hemorrhage, the amount and speed of bleeding. A large amount of bleeding in a short period of time in a deeper part of the brain will mostly result in impaired consciousness.
4.Ocular symptoms
Unequal pupil size often occurs in patients with increased intracranial pressure; there can also be hemianopia and eye movement disorders, such as cerebral hemorrhage patients often stare at the bleeding side of the brain with both eyes in the acute stage.
5.Headache and dizziness
Headache is the first symptom of cerebral hemorrhage, often located on the bleeding side of the head; when there is increased intracranial pressure, the pain can develop to the whole head. Dizziness is often accompanied by headache, especially in cerebellar and brainstem hemorrhage.
III. Examination
1.CT examination
CT scan of the skull and brain can clearly show the site of hemorrhage, the size of hemorrhage, the morphology of the hematoma, whether it breaks into the ventricle, and whether there are low-density edema bands and occupational effects around the hematoma. The lesions are mostly round or ovoid uniform high-density areas with clear boundaries, and when there is a large amount of blood in the ventricles, they are mostly high-density casts with enlarged ventricles. 1 week later, there is circumferential enhancement around the hematoma, and the hematoma is hypodense or cystic after absorption. Dynamic CT examination can also evaluate the progression of hemorrhage.
2.MRI and MRA examination
It is better than CT scan for detecting structural abnormalities, for detecting hemorrhagic foci in the brainstem and cerebellum and for monitoring the evolution of cerebral hemorrhage, but less than CT for diagnosing acute cerebral hemorrhage.
3.Other tests
Including blood routine, blood biochemistry, coagulation function, electrocardiogram and chest X-ray examination. Peripheral leukocytes may be temporarily increased, blood glucose and urea nitrogen levels may also be temporarily increased, and abnormal prothrombin time and partial thromboplastin time suggest coagulation dysfunction.
IV. Diagnosis
In middle-aged and elderly patients, sudden onset during activity or emotional excitement, rapid onset of focal neurological deficits and symptoms of cranial hypertension such as headache and vomiting should be considered as possible cerebral hemorrhage, and combined with cranial CT examination, a clear diagnosis can be made quickly.
V. Treatment
Internal treatment
The principles of treatment are quiet bed rest, dehydration and cranial pressure lowering, blood pressure adjustment, prevention and control of continued bleeding, and strengthening nursing care to prevent and control complications in order to save life, reduce mortality, disability and recurrence.
1. Generally, bed rest should be provided for 2-4 weeks, keeping quiet and avoiding emotional excitement and elevated blood pressure. Closely observe body temperature, pulse, respiration and blood pressure and other vital signs, and pay attention to pupil changes and changes in consciousness.
2. Keep the respiratory tract unobstructed and clear respiratory secretions or inhalants. If necessary, perform tracheal intubation or incision in a timely manner; those with impaired consciousness and gastrointestinal bleeding: fasting for 24 to 48 hours, and emptying the stomach contents if necessary.
3, water, electrolyte balance and nutrition, daily fluid intake can be calculated based on urine volume + 500ml, if there is high fever, excessive sweating, vomiting, maintain central venous pressure 5 to 12mmHg or pulmonary wedge pressure at the level of 10 to 14mmHg. Pay attention to prevent water-electrolyte disorders, which may aggravate cerebral edema. Replenish sodium, potassium, sugar and calories daily.
4.Adjust blood glucose. If blood glucose is too high or too low, correct it promptly and maintain blood glucose level between 6 and 9 mmol/L.
5, obvious headache, excessive irritability, appropriate sedative analgesic; constipation can be used to slow laxative.
6, reduce intracranial pressure, cerebral edema after cerebral hemorrhage reaches a peak in about 48 hours, and gradually subsides after maintaining 3-5 days, which can last 2-3 weeks or longer. Cerebral edema can increase the 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.
Generally speaking, if the condition is critical and the intracranial pressure is too high and the conservative medical treatment is not effective, surgical treatment should be carried out in time.
8. After cerebral hemorrhage, as long as the patient’s vital signs are stable and the condition no longer progresses, it is advisable to carry out rehabilitation treatment as early as possible. Early comprehensive rehabilitation treatment in stages is beneficial to restore the patient’s neurological function and improve the quality of life.
Surgical treatment
1.Minimally invasive drilling and drainage;
2.Small bone window hematoma removal;
3.Large bone flap open cranial hematoma removal;
4.Patients with vascular malformation or aneurysm need microsurgery or interventional treatment after DSA examination.