Hemorrhagic stroke is a spontaneous (non—traumatic) hemorrhage in the cranial cavity. The term “hemorrhagic stroke” is used, as a rule, to refer to intracerebral hemorrhage that occurred as a result of some vascular disease of the brain: atherosclerosis, hypertension and amyloid angiopathy. The most common hemorrhagic stroke occurs against the background of high blood pressure. The clinical picture is characterized by an acute onset and rapid development of symptoms that directly depend on the localization of vascular catastrophe. Hemorrhagic stroke requires urgent hemostatic, antihypertensive and decongestant therapy. According to the indications, surgical treatment is performed.
ICD 10
I61 Intracerebral hemorrhage
Etiology and pathogenesis
The causes of hemorrhagic stroke may be various pathological conditions and diseases: aneurysm, arterial hypertension of various genesis, arteriovenous malformation of the brain, vasculitis, systemic connective tissue diseases. In addition, hemorrhage can occur during treatment with fibrinolytic agents and anticoagulants, as well as as a result of the abuse of drugs such as cocaine, amphetamine.
Most often, a hemorrhagic stroke occurs with amyloid angiopathy and hypertension, when pathological changes occur in the arteries and arterioles of the parenchyma of the brain. Therefore, intracerebral hemorrhages are most often the result of hemorrhagic stroke in these diseases.
Classification
Intracranial hemorrhages are classified depending on the localization of the spilled blood. There are the following types of hemorrhages:
- intracerebral (parenchymal)
- subarachnoid
- ventricular
- mixed (subarachnoid-parenchymal-ventricular, parenchymal-ventricular, etc.)
Symptoms
Hemorrhagic stroke is characterized by an acute onset, most often against the background of high blood pressure. Hemorrhage is accompanied by acute headache, dizziness, nausea, vomiting, rapid development of focal symptoms, followed by a progressive decrease in the level of wakefulness — from moderate stun to the development of a comatose state. The onset of subcortical hemorrhages may be accompanied by an epileptiform seizure.
The nature of focal neurological symptoms depends on the location of the hematoma. Among the most frequent symptoms should be noted hemiparesis, frontal syndrome (in the form of impaired memory, behavior, criticism), sensitivity and speech disorders.
An important role in the patient’s condition immediately after hemorrhage, as well as in the following days, is played by the severity of cerebral and dislocation symptoms due to the volume of intracerebral hematoma and its localization. In the case of extensive hemorrhage and hemorrhage of deep localization, secondary stem symptoms appear very quickly in the clinical picture (as a consequence of brain dislocation). With hemorrhage in the brain stem and extensive cerebellar hematomas, there is a rapid violation of vital functions and consciousness. Hemorrhages with a breakthrough into the ventricular system are more severe than others, when meningeal symptoms, hyperthermia, gormetonic convulsions, rapid depression of consciousness, and the development of stem symptoms manifest themselves.
The first 2.5-3 weeks after hemorrhage is the most severe period of the disease, since at this stage the severity of the patient’s condition is due to progressive swelling of the brain, which manifests itself in the development and increase of dislocation and cerebral symptoms. Moreover, dislocation of the brain and its edema are the main cause of death in the acute period of the disease, when previously existing somatic complications (impaired kidney and liver function, pneumonia, diabetes, etc.) join or decompensate to the above symptoms. By the beginning of the fourth week of the disease, the regression of general cerebral symptoms begins in the surviving patients and the consequences of focal brain damage come to the fore of the clinical picture, which will further determine the degree of disability of the patient.
Diagnostics
The main methods of diagnosis of hemorrhagic stroke:
- MRI of the brain
- spiral CT or conventional CT of the brain
They allow to determine the volume and localization of intracerebral hematoma, the degree of dislocation of the brain and concomitant edema, the presence and area of hemorrhage. It is desirable to conduct repeated CT studies in order to trace the evolution of the hematoma and the state of the brain tissue in dynamics.
Differential diagnosis
First of all, hemorrhagic stroke must be differentiated from ischemic stroke, which happens most often (up to 85% of the total number of strokes). It is not possible to do this based on clinical data alone, therefore it is recommended to hospitalize the patient in a hospital with a preliminary diagnosis of stroke. At the same time, the hospital should have MRI and CT equipment at its disposal in order to conduct an examination as early as possible. Among the characteristic signs of ischemic stroke, attention should be paid to the absence of meningeal symptoms, a slow increase in general cerebral symptoms. In ischemic stroke, the cerebrospinal fluid examined by lumbar puncture has a normal composition, in hemorrhagic stroke, blood content is possible in it.
It is necessary to differentiate intracerebral hematomas of hypertensive genesis from hematomas of other etiology, hemorrhages in the focus of ischemia and tumors. At the same time, the age of the patient, the localization of the hematoma in the brain substance, and the anamnesis of the disease are of great importance. Localization of hematoma in the mediobasal parts of the frontal lobe is typical for cerebral/anterior connective artery aneurysms. With aneurysms of the internal carotid or middle cerebral artery, the hematoma is localized, as a rule, in the basal parts of the frontal and temporal lobes adjacent to the Sylvian fissure. With the help of MRI, you can see the aneurysm itself, as well as pathological vessels of arteriovenous malformation. In case of suspected rupture of an aneurysm or arteriovenous malformation, an angiographic examination is necessary.
Treatment
Treatment of hemorrhagic stroke can be conservative or surgical. The choice in favor of one or another method of treatment should be based on the results of a clinical and instrumental assessment of the patient and consultation with a neurosurgeon.
Drug therapy is performed by a neurologist. The basics of conservative treatment of hemorrhagic stroke correspond to the general principles of treatment of patients with any type of stroke. If a hemorrhagic stroke is suspected, it is necessary to start carrying out therapeutic measures as early as possible (at the pre-hospital stage). At this time, the main task of the doctor is to assess the adequacy of external respiration and cardiovascular activity. To correct respiratory failure, intubation is performed with the connection of a ventilator. Disorders of the cardiovascular system consist, as a rule, in severe arterial hypertension, therefore, blood pressure should be normalized as soon as possible. One of the most important measures that should be carried out upon the patient’s arrival at the hospital is therapy aimed at reducing brain edema. To do this, hemostatic drugs and drugs that reduce the permeability of the vascular wall are used.
Correcting blood pressure in hemorrhagic stroke, it is necessary to avoid a sharp decrease in it, since such significant changes can cause a decrease in perfusion pressure, especially with intracranial hematoma. The recommended blood pressure level is 130 mm Hg. To reduce intracranial pressure, saluretics are used in combination with osmodiuretics. At the same time, it is necessary to monitor the level of electrolytes in the blood at least twice a day. In addition to the above groups of drugs, intravenous administration of colloidal solutions, barbiturates are used for the same purposes. The drug therapy of hemorrhagic stroke should be accompanied by monitoring of the main indicators that characterize the state of the cerebrovascular system and other vital functions.
Surgical treatment. The decision on surgical intervention should be based on several factors — the localization of the hematoma, the volume of blood spilled, the general condition of the patient. Numerous studies have not been able to give an unambiguous answer about the expediency of surgical treatment of hemorrhagic stroke. According to some studies, in certain groups of patients and with certain studies, a positive effect of surgery is possible. At the same time, the main purpose of surgical intervention is to be able to save the patient’s life, therefore, in most cases, operations are carried out in the shortest possible time after hemorrhage. It is possible to postpone the operation only if its purpose is to remove a hematoma for more effective removal of focal neurological disorders.
When choosing the method of surgery, it should be based on the localization and size of the hematoma. Thus, lobar and lateral hematomas are removed by direct transcranial method, and stereotactic, as more gentle, in the case of mixed or medial stroke. However, after stereotactic removal of the hematoma, bleeding relapses occur more often, since thorough hemostasis is impossible during such an operation. In some cases of hemorrhagic stroke, in addition to removing the hematoma, there is a need for ventricular drainage (external ventricular drains), for example, in the case of massive ventricular hemorrhage or occlusive dropsy (with cerebellar hematoma).
Forecast
In general, the prognosis for hemorrhagic stroke is unfavorable. The total percentage of deaths reaches seventy, in 50% death occurs after removal of intracerebral hematomas. The main cause of deaths is progressive edema and dislocation of the brain, the second most common cause is recurrent hemorrhage. About two-thirds of patients who have suffered a hemorrhagic stroke remain disabled. The main factors determining the course and outcome of the disease are the volume of hematoma, its localization in the brain stem, blood breakthrough into the ventricles, disorders of the cardiovascular system preceding hemorrhagic stroke, as well as the elderly age of the patient.
Prevention
The main preventive measures that can prevent the development of hemorrhagic stroke are timely and adequate medical treatment of hypertension, as well as the elimination of risk factors for its development (hypercholesterolemia, diabetes mellitus, alcoholism, smoking).