Hemorrhagic stroke

Hemorrhagic stroke - any spontaneous (non-traumatic) hemorrhage into the cavity of the skull. However, the term "hemorrhagic stroke" in clinical practice is used, as a rule, to denote an intracerebral hemorrhage caused by the most common cerebrovascular diseases: hypertensive disease, atherosclerosis and amyloid angiopathy.

[1], [2], [3], [4]

Epidemiology

Epidemiology of hemorrhagic stroke

Hemorrhagic stroke is 8-15% of all strokes.

The polyethiologic nature of hemorrhagic stroke causes the possibility of its development at any age, including children, however, if we take into account the most common etiologic factors, the most often hemorrhage in the brain is transferred at the age of 50-70 years.

[5], [6], [7], [8], [9], [10], [11], [12], [13], [14],

Causes of the hemorrhagic stroke

Causes of hemorrhagic stroke

The cause of hemorrhagic stroke is the release of blood beyond the vascular bed into the brain substance, the ventricles, or under the membranes of the brain. Hemorrhagic strokes account for up to 15% of the number of all disorders of the cerebral circulation.

The cause of hemorrhagic stroke can be various diseases and pathological conditions: arterial hypertension of various genesis, amyloid angiopathy, aneurysms and vascular malformations of the central nervous system, blood diseases (erythremia, thrombophilia), vasculitis, systemic connective tissue diseases. Hemorrhages may occur with treatment with anticoagulants and fibrinolytic drugs, as well as with the abuse of other drugs (eg, amphetamine, cocaine).

The most common causes of hemorrhagic stroke are hypertension and amyloid angiopathy. The pathogenesis of hemorrhage in these diseases is associated with pathological changes in the arteries and arterioles of the parenchyma of the brain, therefore, intracerebral hemorrhages with the formation of intracerebral hematomas are most typical for them.

The causes of hemorrhagic stroke are as follows:

• In 60-70% of patients, the cause is arterial hypertension.
• In 20% of cases - arterial aneurysm or arteriovenous malformation.
• Approximately in 8-10% - various vascular lesions against the background of atherosclerosis.
• Spontaneous hemorrhage into the subarachnoid space in 70-80% of cases is caused by ruptures of arterial aneurysms (AA), in 5-10% - arteriovenous malformations (LVM).
• Breaking the blood coagulation system and taking anticoagulants are very rarely the cause of subarachnoid hemorrhage (SAH).
• In 15% of cases the source of bleeding remains unset.

[15], [16], [17]

Symptoms of the hemorrhagic stroke

Symptoms of hemorrhagic stroke

The clinical picture of an intracerebral hemorrhage is rather typical. Hemorrhagic stroke has a sharp sudden onset, often against a background of high blood pressure. Characteristic of severe headache, dizziness, nausea and vomiting, the rapid development of focal symptoms, followed by a progressive decrease in the level of wakefulness - from moderate stun to coma. Oppression of consciousness can be preceded by a short period of psychomotor agitation. Subcortical hemorrhages can begin with an epileptiform seizure.

Focal neurological symptoms of hemorrhagic stroke depend on the localization of the hematoma. Typical focal symptoms, taking into account the most frequent localization of intracerebral hematomas are hemiparesis, speech and sensitivity disorders, frontal symptoms in the form of memory disorders, criticism, behavior.

The severity of the patient's condition immediately after the hemorrhage and in the following days depends primarily on the severity of cerebral and dislocation symptoms, in turn due to the volume of the intracerebral hematoma and its localization. With extensive hemorrhages and hemorrhages of deep localization, a secondary clinical symptom appears rather quickly in the clinical picture, due to the dislocation of the brain. For hemorrhages in the brain stem and extensive hematomas of the cerebellum, a rapid disturbance of consciousness and vital functions is characteristic. The most severe bleeding occurs with a breakthrough into the ventricular system. They are characterized by the appearance of hormonal convulsions, hyperthermia, meningeal symptoms, rapid suppression of consciousness, development of stem symptoms.

The severity of focal symptoms in parenchymal hemorrhages depends mainly on the localization of the hematoma. Small hematomas in the area of the inner capsule can lead to a much more coarse focal syndrome than larger hematomas located in the functionally less significant parts of the brain.

The course of hemorrhagic stroke

The most severe period of hemorrhage, especially with extensive hematomas, is the first 2-3 weeks of illness. The severity of the patient's condition at this stage is determined both by the hematoma itself and by the edema of the brain that grows in the first days of the disease, which manifests itself in the development and progression of cerebral and dislocation symptoms. Edema and dislocation of the brain become the main cause of death of patients in the acute period of the disease. For this period, the addition or decompensation of previously existing somatic complications (pneumonia, dysfunction of the liver and kidneys, diabetes mellitus, etc.) are also typical. In connection with immobility of the patient, pulmonary embolism is a great danger at this stage of the disease. By the end of the 2-3-rd week of the disease, the recurrence of cerebral symptoms begins in the surviving patients, the consequences of focal brain lesions come to the fore, which subsequently determine the degree of disability of the patient.

Forms

Classification of hemorrhagic stroke

Intracranial hemorrhages, depending on the location of the outflow of blood, are divided into intracerebral (parenchymal), subarachnoid, ventricular and mixed (parenchymal-ventricular, subarachnoid-parenchymal, subarachnoid-parenchymal-ventricular, etc.). The type of hemorrhage depends largely on the etiologic factor.

Intracerebral hematomas

ICD-10 codes:

I61.0-I61.9. Intracerebral haemorrhage.

Intracerebral hematomas, in addition to etiology, are subdivided according to localization and volume. In the vast majority of cases (up to 90%), hematomas are localized in the supratentorial regions of the brain. There are lobar, lateral, medial and mixed intracerebral hematomas.

• Lobar hemorrhages are hemorrhages in which blood does not go beyond the cortex and white matter of the corresponding lobe, or lobes, of the brain.
• Hemorrhages in the subcortical nucleus (outside of the inner capsule) is commonly referred to as a lateral stroke, and hemorrhage in the thalamus is a medial stroke (inside of the inner capsule).
• In practice, mixed intracerebral hematomas are most commonly encountered when blood is spreading within several anatomical structures.

Hematomas of the posterior cranial fossa account for about 10% of all intracerebral hematomas. Most often they are located in the cerebellum, less often - in the brain stem, where their "favorite" localization is the bridge.

Hemorrhages in the medial parts of the cerebral hemispheres, as well as bruises of the posterior cranial fossa, are approximately 30% of cases accompanied by a breakthrough of blood into the ventricular system.

The volume of intracerebral hematomas with hemorrhagic stroke can vary within very wide limits - from a few milliliters to 100 ml or more. There are different ways to determine the volume of the hematoma. The simplest of them is the method of calculating the volume from CT data using the following formula: maximum height x maximum length x maximum width: 2. Distribution of hematomas by volume is very conditional. It is accepted to divide into small (up to 20 ml), medium (20-50 ml) and large (> 50 ml) hematomas. Small, medium and large hematomas occur approximately at the same frequency.

[18], [19], [20], [21], [22]

Diagnostics of the hemorrhagic stroke

Diagnosis of hemorrhagic stroke

The main diagnostic method for acute impairment of cerebral circulation is CT or MRI. These methods allow to differentiate the type of stroke, determine the localization and volume of intracerebral hematoma, the degree of concomitant edema and dislocation of the brain, the presence and prevalence of ventricular hemorrhage. Research should be performed as early as possible, since its results largely determine the tactics of management and treatment of the patient. Repeated CT studies are also needed to track the evolution of the hematoma and the state of the brain tissue in dynamics. The latter is especially important for the timely correction of drug therapy. Evaluation of CT data, as a rule, does not present difficulties, regardless of the period that has elapsed since the onset of the disease. Interpretation of MRI data seems more complicated, due to the change in MP signal depending on the evolution of the hematoma. The most frequent mistaken diagnosis is "intracerebral swelling with hemorrhage."

[23], [24]

Differential diagnosis of hemorrhagic stroke

Hemorrhagic stroke should be differentiated first of all from ischemic stroke, comprising up to 80-85% of all strokes. To make an accurate diagnosis is necessary to begin the appropriate therapy as soon as possible. Differential diagnosis by clinical data is not always possible, so it is preferable to hospitalize patients with a diagnosis of "stroke" in hospitals equipped with CT or MRT equipment. Ischemic stroke is characterized by a slower increase in cerebral symptoms, the absence of meningeal symptoms, in some cases - the presence of precursors in the form of transient disorders of the cerebral circulation, heart rhythm disturbances in the anamnesis. Likvor, taken with the help of a lumbar puncture, with ischemic stroke has a normal composition, with hemorrhagic - it can contain an admixture of blood. It is necessary to emphasize that, with the general severe condition of the patient, it is better not to do the lumbar puncture or to perform with great care, as removing the cerebrospinal fluid can cause a dislocation of the brain. Intracerebral hematomas of hypertensive genesis must also be differentiated from the hematoma of another etiology, as well as from hemorrhages to the ischemia focus or tumor. Of great importance in this case are the history of the disease, the age of the patient, the localization of the hematoma in the brain substance. With hemorrhage from an aneurysm, the hematomas have a typical localization - the medialboreal parts of the frontal lobe with an aneurysm of the anterior cerebral / anterior connective artery and the basal parts of the frontal and temporal lobes adjacent to the sylvium gap, with an aneurysm of the internal carotid or middle cerebral artery. With MRI, one can also see the aneurysm itself or the pathological vessels of arterio-venous malformation. If there is a suspicion of rupture of an aneurysm or an arterio-venous malformation, which the young age of the patient may firstly indicate, an angiographic examination is necessary.

[25], [26]

Treatment of the hemorrhagic stroke

Treatment of hemorrhagic stroke

Treatment of patients with intracerebral hematoma may be conservative and surgical.

The question of the tactics of treatment should be decided on the basis of the results of a comprehensive clinical and instrumental assessment of the patient and mandatory consultation of a neurosurgeon.

Medication for hemorrhagic stroke

Principles of conservative treatment of patients with intracerebral hematomas correspond to the general principles of treatment of patients with any kind of stroke. Arrangements for the treatment of a patient with suspected intracerebral hematoma should be started at the prehospital stage, where the adequacy of external respiration and cardiovascular activity should be assessed first. With signs of respiratory failure, intubation with the connection of ventilation is necessary. In the correction of the state of the cardiovascular system, the most important is the normalization of blood pressure: as a rule, in patients with hemorrhagic stroke it is sharply increased.

In the hospital should continue to ensure adequate external respiration and oxygenation of the blood, the normalization of the functions of the cardiovascular system, maintaining the water-electrolyte balance. The most important event is the provision of therapy aimed at reducing the edema of the brain. Recommended use of hemostatic drugs and drugs that reduce the permeability of the vascular wall. It is necessary to prevent thromboembolism. Careful care of the patient is very important.

When correcting blood pressure, it should avoid its sharp and significant decrease, as this can lead to a decrease in perfusion pressure, especially in conditions of intracranial hypertension. It is recommended to maintain a mean arterial pressure at a level of 130 mm Hg. To reduce intracranial pressure, osmo-diuretics in combination with saluretics are used, provided that blood electrolytes are monitored at least 2 times a day, barbiturates, and intravenous colloidal solutions. The use of glucocorticoids is ineffective. Medical therapy should be performed in conditions of monitoring of the main indicators characterizing the state of the cerebrovascular system and vital functions. The amount of monitoring depends on the severity of the patient.

When treating a patient with an intracerebral hematoma, it must be taken into account that hypertension leads to the defeat not only of the cerebral vascular system, but also of other organs and systems. Patients with hypertension often have various concomitant diseases (diabetes, atherosclerosis, obesity), therefore, patients with intracerebral hematoma are characterized by rapid attachment of various somatic complications.

Surgical treatment of hemorrhagic stroke

The decision of the question of indications for surgical intervention concerning an intracerebral hematoma depends on many factors, the most important of them - the volume, the location of the outflow of blood and the state of the patient. Despite numerous studies concerning the advisability of surgical treatment of intracerebral hematomas, there is no consensus on this issue. Randomized trials failed to prove the advantages of a particular method. Non-randomized studies indicate the effectiveness of the operation under certain conditions and in certain groups of patients.

In substantiating the operation, the main goal is saving the patient's life, so most interventions are performed as soon as possible after hemorrhage. In some cases, hematomas can be removed in order to more effectively eliminate focal neurological disorders. Such operations can be delayed.

A comparative analysis of the results of conservative and surgical treatment has shown that with supratentorial hematomas with a volume of up to 30 ml, surgical treatment is impractical regardless of the localization of the hematoma, since hematomas of small volume are rarely the cause of vital disorders. With a hematoma of more than 60 ml, the outcome is generally worse with conservative treatment. In patients with hematomas of medium volume (30-60 ml), it is most difficult to determine the indications for surgery and choose the method of surgical intervention. In these cases, the degree of impairment of consciousness, the severity of dislocation symptoms, the localization of the hematoma, the severity of perifocal edema of the brain, the presence of concomitant ventricular hemorrhage are prognostically significant. Contraindication to the operation is considered a coma, especially with a marked violation of stem functions, as when trying to operate these patients, the lethality reaches 100%. The localization of hematomas in deep structures is unfavorable.

With hematomas of the cerebellum, the indication for surgery is broader, since hematomas of this localization can lead to rapid disruption of vital functions.

Thus, surgical interventions aimed at removal of intracerebral hematoma are indicated mainly in patients with lobar or lateral hematomas with a volume of more than 50 ml, as well as patients with cerebellar hematomas.

The choice of the method of operation depends primarily on the location and size of the hematoma. Lobar and lateral bruises are best removed directly. In recent years, a puncture-aspiration method with local fibrinolysis has been widely used. With medial and mixed strokes, it is considered more sparing to stereotaxically remove hematomas. However, with stereotaxic removal, recurrences of bleeding occur more often, since during the operation it is impossible to conduct a thorough haemostasis.

In addition to removal of hematomas with hemorrhagic stroke, there may be a need for ventricular drainage. The application of external ventricular drainage is indicated in cases of massive ventricular hemorrhage, occlusal edema in patients with cerebellar hematomas, as well as for monitoring intracranial pressure.

Prevention

How to prevent hemorrhagic stroke?

Adverse outcomes of hemorrhagic stroke once again underline the crucial importance of disease prevention. The main measures in this direction are as early as possible to identify and conduct systematic adequate drug treatment of patients suffering from hypertension, which allows to reduce the risk of stroke by 40-50%, as well as eliminate risk factors for hypertension and stroke: smoking, large doses of alcohol, diabetes, hypercholesterolemia.

Forecast

What prognosis does hemorrhagic stroke have?

The prognosis for hemorrhagic stroke is generally unfavorable. The overall lethality reaches 60-70%, after removal of intracerebral hematomas - about 50%. The main causes of death of both operated and unoperated patients are an increasing edema and dislocation of the brain (30-40%). The second most frequent cause is a recurrence of hemorrhage (10-20%). Approximately 2/3 of the patients who suffered a stroke remain disabled. The main factors determining the outcome of the disease, consider the volume of hematoma, the concomitant breakthrough of blood in the ventricles, the localization of the hematoma in the brainstem, the previous reception of anticoagulants, the previous heart disease, the elderly.