Intraventricular hemorrhage is one of the types of acute cerebral circulatory disorders – the most common pathology in neurology. The development of hemorrhage in the brain, as a rule, is promoted by untreated persistent hypertension, alcohol abuse, smoking, taking drugs that violate blood clotting. The diagnosis is made on the basis of collecting the patient’s life history and conducting a series of examinations (MRI or CT, ECG). Treatment is aimed at eliminating brain edema, normalization of respiratory function and blood pressure.
ICD 10
I61.5 Intracerebral hemorrhage intraventricular
General information
Intraventricular hemorrhage is a pathology that belongs to the ACVA according to the hemorrhagic type. This pathology ranks first in terms of mortality in the world.
According to medical statistics, hemorrhage in the brain leads to death in the first 2 days in 40-60% of cases. The percentage ratio increases during the first year after a stroke and reaches about 90%. The development of hemorrhage is more typical for people over 50 years old suffering from persistent arterial hypertension, however, it can also occur with other pathologies not related to blood pressure indicators.
Classification
The classification of intraventricular hemorrhage was developed more than 20 years ago and entered into the international classification of diseases 10 revision. According to ICD-10, IVH is divided into several stages: subependimal hemorrhage (SEC), SEC with spread to the lateral ventricles of the brain, SEC with spread to the ventricles and into the brain substance. In clinical practice, specialists in the field of neurology distinguish 3 types of intraventricular hemorrhages: hemorrhage in the lateral ventricles, in the III ventricle and in the IV ventricle.
Hemorrhage into the lateral ventricle occurs from the brain tissues adjacent to it and is characterized by a gradual filling of the volume of the lateral ventricles with the spread of blood into the III ventricle and further. With a large amount of blood spilled, there is a significant increase in brain volume with the development of bilateral neurological symptoms. If the hemorrhage is accompanied by the filling of only one lateral ventricle, it has a more favorable course and symptoms resembling a normal parenchymal hemorrhage.
The breakthrough of blood into the III ventricle occurs from the medial foci of parenchymal hemorrhages. At the same time, there is an acute development of neurological symptoms, often leading to a fatal outcome. Hemorrhage in the IV ventricle arises from the dorsal part of the trunk or cerebellum. This type of hemorrhage often has a lethal ending.
Causes
Intraventricular hemorrhage are divided into primary and secondary. Primary ventricular hemorrhages associated with arterial hypertension or amyloidosis of cerebral vessels are rare. According to some observations, they make up 1 case out of 300. Secondary hemorrhages are caused by factors such as uncontrolled intake of antiplatelet agents and fibrinolytics, intracranial aneurysm (local thinning and bulging of the cerebral blood vessel wall with subsequent breakthrough), oncological neoplasms of the brain.
Intraventricular hemorrhage is usually characterized by rapidly developing depression of consciousness. Coma often occurs in the first hours after a stroke. Only in the case of a gradual outpouring of blood and a small amount of it, the patient’s consciousness can be preserved for a long time and is gradually lost. As a rule, hemorrhage in the ventricles is accompanied by shell symptoms and vomiting. A vegetative symptom complex is characteristic: hyperhidrosis and chills-like tremor; pallor, and then hyperemia of the face, limbs and trunk; the initial decrease in temperature with a rapid change to hyperthermia, reaching 41-42 ° C.
One of the typical signs of intracerebral hemorrhage in the ventricles is a disorder of muscle tone in the form of gormetonic syndrome or decerebration rigidity. In the first case, an increase in muscle tone of the affected limbs occurs in a paroxysmal manner. An attack of gormetonia may occur in response to external stimuli. With decerebration rigidity, muscle tone is increased mainly in the extensor muscles. The patient lies with his back arched and his head thrown back. His hands and fingers are bent, his forearms are turned inward.
Often, hemorrhage into the ventricles of G.M. is accompanied by paresis of the extremities opposite to the parenchymal hemorrhagic focus, the appearance of motor automatism in nonparetic limbs, increased tendon reflexes, the presence of pathological and absence of abdominal reflexes, a disorder of the functioning of pelvic organs. With hemorrhage in the III ventricle, respiratory and circulatory disorders come to the fore, the gormetonic syndrome is bilateral in nature. Hemorrhage in the IV ventricle is accompanied by hiccups and swallowing disorders, spontaneous movements are absent, the phenomena of gormetonia are poorly expressed.
With continued hemorrhage into the ventricles due to an increase in the volume of blood flowing, a sharp increase in intracranial pressure, increasing swelling of the brain and compression of nerve centers responsible for the life support of the body, the symptoms of respiratory and cardiovascular disorders worsen. There is a violation of the rhythm and frequency of breathing, short-term initial bradycardia is replaced by tachycardia up to 120-150 beats / min., arrhythmia occurs.
Depending on the rate of bleeding during ventricular hemorrhage, the patient’s condition worsens. The hormonal syndrome decreases, hypotension gradually develops and automatic movements disappear, cross pathological reflexes appear. Then complete atony and areflexia develop.
Diagnostics
The diagnosis of “cerebral ventricular hemorrhage” is made on the basis of a systematic assessment of the patient’s medical history: the presence of blood diseases, previously suffered hemorrhagic strokes, taking medications that affect the blood clotting system, etc., acute occurrence and rapid development of severe clinical symptoms; neurological examination data and additional studies.
If a intraventricular hemorrhage is suspected, the patient should be taken to the hospital as soon as possible. It is possible that he will have to be resuscitated in an ambulance. In a hospital setting, to confirm the diagnosis, the patient is carried out: an MRI or CT scan of the brain, a blood test counting the number of platelets, a coagulogram is examined, ECG and blood pressure are monitored.
If it is not possible to conduct an MRI or CT scan, then the patient is given an echoencephalography, which allows to determine the presence of a displacement of the mid-brain structures. In some cases, a lumbar puncture is required to differentiate intraventricular hemorrhage, in which blood enters the cerebrospinal fluid, from an ischemic stroke. More accurately diagnose intraventricular hemorrhage allows diagnostic puncture of the ventricle.
Treatment and prevention
Treatment of intraventricular hemorrhage, first of all, is aimed at the speedy organization of medical care and the immediate conduct of basic therapy: normalization of cardiopulmonary function, control of blood pressure, regulation of the constancy of the internal environment of the body. In addition, symptomatic treatment is carried out: the introduction of anticonvulsants, if necessary, the introduction of drugs to relieve cerebral edema and normalize intracranial pressure, the introduction of antiemetic drugs.
A clear specific therapy of intraventricular hemorrhage, aimed at stopping bleeding, is currently under development. Pathogenetic therapy consists mainly in maintaining optimal blood pressure figures and evacuation of spilled blood by surgical methods. Neuroprotective therapy can also be attributed to pathogenetic therapy: the use of neurotrophic drugs (hydralizates from calf blood serum, piracetam, glycine), antioxidants (methylethylpyridinol, meldonium, vit. F), calcium channel blockers (nimodipine, nicardipine), medications that improve metabolism (cytochrome C, inosine, L-carnitine, ATP).
The question of surgical treatment of intraventricular hemorrhage is solved in each case separately. Evacuation of parenchymal hematoma and puncture aspiration of blood from the ventricles can reduce intracranial compression and dislocation of brain structures. An indication for ventricular drainage or endoscopic evacuation of a hematoma may be a medial stroke with a breakthrough into the ventricles. Surgical intervention can be effective if there is data for an aneurysm or AVM of cerebral vessels. According to some clinical observations, with the development of a comatose state, surgical treatment is advisable only in the first 6-12 hours.
In addition to the main treatment, special attention is paid to the prevention of somatic complications – bedsores, respiratory distress syndrome, pneumonia, urogenital infection, stress ulcers.
Prevention of the development of acute circulatory disorders of hemorrhagic type, including ventricular hemorrhages, are: timely treatment of hypertension, maintaining a healthy lifestyle, taking medications only as prescribed by a doctor, timely detection and correction of diseases with blood clotting disorders.
