Intracerebral hemorrhage is a limited accumulation of blood in the substance of the brain, which has a squeezing, displacing and damaging effect on the brain tissue located nearby. Disease is clinically characterized by cerebral and focal symptoms, which depend on the location of the hematoma and its volume. Hemorrhage is most reliably diagnosed by the combined use of CT and MRI of the brain, as well as angiographic examination of brain vessels. A small form can be treated conservatively, a large — only surgically, by removal or aspiration.
I61 Intracerebral hemorrhage
Intracerebral (intraparenchymatous) hematoma is a type of intracranial hematoma characterized by accumulation of blood in the parenchyma of the brain. More often it has a post-traumatic origin. In the structure of all intracranial hematomas, disease account for about 30%. They are diagnosed several times more often in men. The age peak falls on the young working age – from 35 to 50 years. They pose a serious danger due to the severity of developing cerebral disorders and a high mortality rate.
Depending on the genesis, intracranial hematomas can be post-traumatic and non-traumatic. Intracerebral hemorrhage can be formed as a result of:
- TBI. Most often, the outpouring of blood is facilitated by the rupture of a cerebral vessel at the time of a traumatic brain injury or post-traumatic diapedesis bleeding in a contusion focus.
- Pathology of cerebral vessels. The immediate cause is a rupture of a brain aneurysm or an arterio-venous malformation.
- Arrosive bleeding. Destruction of the vascular wall can develop in intracerebral tumors, due to excessive increase in intravascular pressure in hypertension and / or impaired elasticity of the vascular wall in atherosclerosis, systemic vasculitis, diabetic macroangiopathy, etc.
Changes in the properties of blood. Intracerebral hemorrhage may be associated with changes in the rheological properties of blood in hemophilia, leukemia, liver diseases (chronic hepatitis, cirrhosis), treatment with anticoagulants, etc.
An intracerebral hemorrhage can consist of both liquid and clotted blood. In some cases, in addition to blood, an intracerebral hemorrhage contains cerebral detritus, which in its quantity is significantly inferior to the volume of blood accumulated in the hematoma. The amount of blood that accommodates an intracerebral hemorrhage ranges from 1 to 100 ml. An increase in the size of an intracerebral hemorrhage occurs, as a rule, within 2-3 hours after the onset of bleeding, and with a violation of blood clotting and longer.
The resulting intracerebral hemorrhage compresses the surrounding brain tissues, leading to their damage and necrosis. Along with this, an intracerebral hemorrhage causes an increase in intracranial pressure and can cause cerebral edema. Intracerebral hemorrhage of considerable size can lead to displacement of brain structures and the development of the so-called dislocation syndrome. In addition, bleeding leads to reflex spasm of cerebral vessels and ischemia, primarily in areas located near the hematoma.
Ischemia is an additional damaging factor that leads to the spread of pathological changes far beyond the boundaries of the resulting hematoma. In about 14% of cases, an intracerebral hemorrhage breaks into the ventricles of the brain, leading to ventricular hemorrhage. According to some data, in 23% of cases intracerebral hemorrhage is combined with the formation of subdural, epidural or epi-subdural hematoma in the membranes of the brain.
To date, clinical neurology uses several classifications of intracerebral hemorrhage, giving an idea of their various characteristics: location, size, etiology. Depending on the localization, there are central, subcortical and cortical-subcortical intracerebral hemorrhage, as well as cerebellar hematoma. There are lobar, medial, lateral and mixed intracerebral hemorrhage. According to the size, an intracerebral hemorrhage can be classified as:
- small (up to 20 ml, CT diameter no more than 3 cm)
- medium (20-50 ml, CT diameter 3-4.5 cm)
- large (>50 ml, CT-diameter >4.5 cm).
Due to the occurrence of intracerebral hemorrhage, it can be post-traumatic, hypertensive, aneurysmal, tumor, etc. For posttraumatic hematoma, classification according to the time of its occurrence is applied. Primary intracerebral hemorrhage forms immediately after TBI, delayed intracerebral hemorrhage — after a day or more.
General cerebral symptoms
In most cases, intraparenchymatous hemorrhage is accompanied by pronounced cerebral symptoms. Patients experience dizziness, intense headache, nausea and vomiting. More than half of cases of intracerebral hemorrhage are characterized by impaired consciousness from sopor to coma. Sometimes the depression of consciousness is preceded by a period of psychomotor agitation. The formation of an intracerebral hemorrhage may occur with the presence of an erased light gap in the patient’s condition, with or without a longer light gap.
Focal symptoms of intracerebral hemorrhage depend on its volume and localization. Thus, with small form in the area of the inner capsule, there is a more pronounced neurological deficit than with significantly large hematomas localized in less functionally significant areas of the brain. The most common intracerebral hemorrhage is accompanied by hemiparesis, aphasia (speech disorder), sensitivity disorders, non-symmetry of tendon reflexes of the right and left extremities, convulsive epileptic seizures. Anisocoria, hemianopsia, frontal symptoms may be observed: criticism and memory disorder, behavior disorder.
Extensive intracerebral hemorrhage quickly leads to the appearance of dislocation syndrome, which occurs as a result of displacement of brain structures. Causing an increase in the volume of the contents of the cranium, intracerebral hemorrhage leads to a displacement of brain structures in the caudal direction and the insertion of the tonsils of the cerebellum into the large occipital foramen. The consequence of this is compression of the medulla oblongata, clinically manifested by stem symptoms: nystagmus, swallowing disorder (dysphagia), respiratory rhythm disorder, diplopia, hearing loss, vestibular ataxia, hypo- or anosmia, strabismus and drooping of the upper eyelid, bradycardia, hyperthermia and an increase in blood pressure.
Hemorrhage in the ventricles
Pathology with a breakthrough of blood into the ventricles is characterized by hyperthermia, rapidly developing depression of consciousness up to coma, the presence of meningeal symptoms, gormetonic convulsions — a paroxysmal increase in muscle tone of the extremities, as a result of which the arms are bent and brought to the trunk, and the legs are maximally unbent.
Disease of a delayed nature is clinically manifested by a lack of improvement in the patient’s condition or a sharp deterioration in his condition a day or more after the injury.
Modern neuroimaging methods allow not only to diagnose intracerebral hemorrhage, but also to identify the cause of its appearance. The leading diagnostic method is:
- CT scan of the brain. As a rule, on tomograms, an intracerebral hemorrhage has the appearance of a focus of homogeneous density of a rounded or oval shape. If a hematoma has formed as a result of a brain injury, then it usually has an uneven contour. Over time, the density of the hematoma decreases to an isodense state, in which its density corresponds to the density of brain tissue. For small hematomas, this period is 2-3 weeks, and for medium—sized ones – up to 5 weeks.
- MRI of the brain. With a decrease in the density of the hematoma, it is better visualized using MRI, although in the initial period, the use of MRI can lead to an erroneous diagnosis in favor of a tumor with hemorrhage. Therefore, if there is such a possibility, many neurologists and neurosurgeons prefer to use both methods of neuroimaging (CT and MRI) during diagnosis.
- Cerebral angiography. In order to identify vascular disorders caused by reflex angiospasm, as well as to diagnose aneurysms and arteriovenous malformations, brain angiography or magnetic resonance angiography (MRA) is used. Angiography cannot be used independently in the diagnosis of intracerebral hemorrhage, since it does not make it possible to accurately differentiate the area of the brain injury from the hematoma.
Intracerebral hemorrhage should be differentiated with a tumor of the cerebral hemispheres, a focus of brain injury, ischemic stroke, cyst and brain abscess.
Intracerebral hemorrhage can be treated conservatively or surgically. The decision on the choice of therapeutic tactics is usually made by a neurosurgeon. Conservative therapy under CT control is possible with an intracerebral hemorrhage diameter of up to 3 cm, a satisfactory state of consciousness of the patient, the absence of clinical data for dislocation syndrome and compression of the medulla oblongata. As part of conservative therapy, hemostatics and drugs that reduce vascular permeability are administered. Prevention of thromboembolism, correction of blood pressure is necessary. Diuretics are used to reduce intracranial pressure under the control of the electrolyte composition of the blood.
A large diameter, pronounced focal symptoms, impaired consciousness are indications for surgical treatment. The presence of signs of compression of the brain stem and/or dislocation syndrome serves as a reason for urgent surgical intervention:
- Transcranial deletion. It is the operation of choice for hematomas of various localization and size.
- Endoscopic evacuation. A less traumatic method of surgical treatment. It is used if technically possible.
- Stereotactic aspiration. It is applicable to small hematomas accompanied by a significant neurological deficit.
With multiple hematomas, only the largest of them is often subject to removal. If an intracerebral hemorrhage is combined with a hematoma of the membranes of the same hemisphere, then its removal is performed together with the removal of a subdural hematoma. If an intracerebral hemorrhage of small or medium size is localized on the other side of the hematoma of the membranes, then it may not be removed.
Prognosis and prevention
The main factors on which the prognosis depends include: the size and location of the hematoma, the age of the patient, the presence of concomitant pathology (obesity, hypertension, diabetes mellitus, etc.), the degree and duration of impaired consciousness, the combination of intracerebral hemorrhage with hematomas of the membranes, the timeliness and adequacy of the medical care provided. The most unfavorable prognosis is for hematomas that break into the ventricles of the brain. The main causes of death are edema and dislocation of the brain. About 10-15% of patients with hemorrhagic stroke die from recurrent hemorrhage, and about 70% have a persistent disabling neurological deficit. Prevention consists in the prevention of head injuries, prevention and timely treatment of cerebrovascular diseases.