Diagnostic criteria.
1. It refers to non-traumatic hemorrhage in the brain parenchyma and is commonly seen in hypertensive patients aged 50-70 years with sudden onset during activity, emotional stress or after alcohol consumption. The symptoms peak in minutes to hours. Common signs and symptoms include increased blood pressure, headache, vomiting. Disorders of consciousness, urinary and fecal incontinence, hemiparesis, aphasia, hemianesthesia, cervical ankylosis, pupillary changes, and in severe cases, death within 24-48 hours. Auxiliary examination: high-density foci can be seen in cranial CT.
2. Physical signs.
(1) Headache and dizziness: headache is the first symptom of cerebral hemorrhage, often located in the head on the side of hemorrhage; when there is an increase in intracranial pressure, the pain can develop to the whole head. Dizziness is often associated with headache, especially in cerebellar and brainstem hemorrhage.
(2) Vomiting: Vomiting occurs in about half of the patients with cerebral gliosis and may be related to increased intracranial pressure, vertigo attacks, and blood irritation of the meninges during cerebral hemorrhage.
(3) Impaired consciousness: manifests as drowsiness or coma, the degree of which is related to the site, amount and rate of cerebral hemorrhage. A large amount of hemorrhage in a short period of time in a deeper part of the brain will mostly result in impaired consciousness.
(4) Motor and speech disorders: motor disorders are more common with hemiparesis; speech disorders mainly manifest as aphasia and slurred speech.
(5) Ocular symptoms: unequal pupil size often occurs in patients with increased intracranial pressure and herniated cells; there can also be hemianopia and eye movement disorders, such as cerebral hemorrhage patients often stare at the bleeding side of the brain in the acute stage.
Cerebral hemorrhage may also be accompanied by cervical tonicity, seizures, and urinary and fecal incontinence. If the patient develops deep coma, high fever, pupil changes and combined gastrointestinal bleeding, the condition is critical and the prognosis is poor.
Treatment measures.
1.Medical treatment
(1) General treatment.
(1) General bed rest for 2 to 4 weeks, keep quiet, avoid emotional excitement and elevated blood pressure. Closely observe body temperature, pulse, respiration, blood pressure and other vital signs, pay attention to pupil changes and changes in consciousness.
② Keep the respiratory tract unobstructed, clear respiratory secretions or suction characters, if Pa02<60mmHg or PaCO2>50mmHg should be oxygenated to maintain the arterial oxygen saturation above 90% and PaCO2 between 25~35mmHg, if necessary, perform tracheal intubation or incision in time; those with impaired consciousness and gastrointestinal bleeding should fast for 24~48 hours, if necessary If necessary, gastric contents should be emptied.
③ Water and electrolyte balance and nutrition, daily fluid intake can be calculated based on urine volume + 500ml, if there is high fever, excessive sweating, vomiting or diarrhea, the amount of fluid intake can be increased appropriately. Maintain central venous pressure at 5-12 mmHg or pulmonary wedge pressure at 10-14 mmHg level. Pay attention to prevent hyponatremia, which may aggravate cerebral edema. Supplement sodium 50～70mmol/L, potassium 40～50mmol/L, sugar 13.5～18g and calories (6.280～7.536)×106J/d daily. ④Adjust blood glucose, if blood glucose is too high or too low, it should be corrected in time to maintain blood glucose level between 6～9mmol/L. ⑤ For obvious headache and excessive irritability, sedative analgesic can be given as appropriate; for constipation, laxative can be used.
(2) Reduce intracranial pressure: cerebral edema reaches its peak in about 48 hours after cerebral hemorrhage and gradually decreases after 3 to 5 days of maintenance, which can last for 2 to 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 (ICP) is an important part of the acute treatment of cerebral hemorrhage. Available options are.
①Mannitol: usually 125-250ml every 6-8 hours for 7-10 days; if there are signs of brain herniation formation, rapid pressure intravenous drip or intravenous push; it should be used with caution for coronary artery disease, myocardial infarction, heart failure and renal insufficiency.
②Diuretics: furosemide is more commonly used, 20-40mg each time, 2-4 times a day intravenously, often used alternately with mannitol to enhance the effect of dehydration, attention should be paid to monitoring renal function and water-electrolyte balance during the use of drugs.
Glycerol fructose: 500ml IV, 1~2 times daily, 3~6 hours, dehydration and lowering cranial pressure are milder than mannitol, used in patients with mild disease, patients with severe disease and patients with renal insufficiency.
④10% human albumin: 50 to 100ml IV, once daily, more suitable for patients with hypoproteinemia, can increase colloid osmotic pressure, with longer lasting effect. It is advisable to monitor ICP and plasma osmolality during dehydration agent administration, and some severe cases require monitoring of central venous pressure. The application of hormone therapy to reduce cerebral edema is not recommended.
(3) Adjustment of blood pressure: There are no certain accepted standards regarding the regulation of blood pressure in patients with ICH. It is generally believed that elevated blood pressure in ICH patients is a vascular autoregulatory response of the body to ICP to ensure blood supply to brain tissue, and that blood pressure will decrease as ICP decreases. However, if the blood pressure is too high, it will increase the risk of rebleeding, and timely blood pressure control is advisable when necessary. The patient’s age, history of hypertension, presence of intracranial hypertension, cause of bleeding and time of onset should be considered when regulating blood pressure.
In general, when the blood pressure is ≥200/110 mmHg, antihypertensive therapy should be taken to maintain the blood pressure at a level slightly higher than the pre-onset level; when the blood pressure is <180/105 mmHg, antihypertensive drugs can be withheld. If the systolic blood pressure is between 180 and 200 mmHg or diastolic blood pressure is between 100 and 110 mmHg, blood pressure should be monitored closely; even if antihypertensive drugs are applied, strong antihypertensive drugs should be avoided to prevent cerebral hypoperfusion caused by too rapid a drop in blood pressure; if the systolic blood pressure is <90 mmHg and there are signs of acute circulatory insufficiency, blood volume should be replenished in time and blood pressure-raising drugs should be given appropriately to maintain adequate cerebral perfusion The blood volume should be replenished and blood pressure raising drugs should be given appropriately to maintain adequate cerebral perfusion. During the recovery period of cerebral hemorrhage, blood pressure should be actively controlled and kept within the normal range as much as possible.
(4) Hemostatic treatment: Hemostatic drugs such as 6-aminocaproic acid, aminoglycolic acid and lithotripsy have little effect on hypertensive atherosclerotic hemorrhage. If there is coagulation dysfunction, hemostatic drugs can be targeted, for example, heparin treatment for cerebral hemorrhage can be neutralized by fisetin, and warfarin treatment for cerebral hemorrhage can be antagonized by vitamin K1.
(5) Subcritical treatment: It is an adjuvant treatment for cerebral hemorrhage, which may have certain effect and can be tried in the clinic.
(6) Prevention and treatment of complications.
(1) Infection: for those with mild disease and no evidence of infection in the early stage of the disease, routine use of antibiotics is generally not recommended; elderly patients with combined impaired consciousness are prone to complications of pulmonary infection or urinary tract infection due to catheterization, etc., and can be given prophylactic antibiotics; if systemic infection has already appeared, antibiotics can be selected according to experience or sputum culture, urine culture and drug sensitivity test results; for those with urinary retention, a catheter should be left in place and, if necessary Perform bladder irrigation if necessary.
②Stress ulcer: it can cause gastrointestinal bleeding. H2 receptor blockers should be applied preventively to patients with severe disease or advanced age; once bleeding occurs, it should be treated according to the treatment routine for upper gastrointestinal bleeding, such as the application of ice saline gastric lavage and local hemostatic drugs.
(3) Abnormal antidiuretic hormone secretion syndrome: also known as dilutional hyponatremia, which can occur in about 10% of patients with ICH, due to increased sodium excretion via urine and decreased blood sodium, aggravating cerebral edema, water intake should be limited to 800-1000ml/day and sodium supplementation 9-12g/day. Hyponatremia should be corrected slowly, otherwise it can lead to central pontine myelinolysis.
④Brain salt depletion syndrome: hyponatremia due to hypersecretion of cardiac natriuretic factor, which should be treated with sodium infusion.
⑤Epileptic seizures: for those with frequent seizures, Valium 10-20mg can be slowly injected intravenously, or phenytoin sodium 15-20mg/kg can be slowly injected to control seizures, and long-term treatment is generally not required.
(6) Central hyperthermia: Most of them are treated with physical cooling, and some scholars propose to use dopaminergic agonists such as bromocriptine for treatment.
(vii) Lower extremity deep vein thrombosis or pulmonary embolism: once it occurs, normal heparin 100mg should be given intravenously once a day or low molecular heparin 4000U subcutaneously twice a day. Prophylactic treatment can also be given to elderly and debilitated bedridden patients as appropriate.
2.Surgical treatment: Generally speaking, when ICH is critically ill resulting in high intracranial pressure and conservative medical treatment is not effective, surgical treatment should be promptly performed.
(1) The purpose of surgical treatment: to remove the hematoma as soon as possible, lower the intracranial pressure, save life, reduce the pressure of the hematoma on the surrounding tissues as early as possible, and reduce the disability rate. At the same time, treatment can be performed for the cause of bleeding, such as cerebrovascular malformation and aneurysm. The main surgical methods include: debridement decompression, small bone window craniotomy, borehole hematoma aspiration and ventricular puncture and drainage, etc.
(2) Indications for surgical treatment: At present, there is no consistent opinion on the indications, methods and timing of surgical procedures, which should be decided mainly according to the bleeding site, etiology, bleeding volume and patient’s age, state of consciousness and general condition. It is generally considered that surgery should be performed at an ultra-early stage (within 6 to 24 hours after the onset).
Surgical treatment is usually considered for the following conditions.
(i) moderate or greater hemorrhage in the basal ganglia region (≥30 ml in the nucleus accumbens and ≥15 ml in the thalamus).
(ii) cerebellar hemorrhage ≥ 10 ml or ≥ 3 cm in diameter, or combined with significant hydrocephalus.
③ severe ventricular hemorrhage (ventricular cast).
3, rehabilitation: After cerebral hemorrhage, as long as the patient’s vital signs are stable and the condition no longer progresses, it is appropriate to carry out rehabilitation treatment as early as possible. Early phased comprehensive rehabilitation treatment is beneficial to restore the neurological function of patients and improve the quality of life.