Intracerebral haemorrhage

Intracerebral haemorrhage is a local bleeding from the blood vessels within the parenchyma of the brain. The most common cause of hemorrhage remains arterial hypertension. Typical manifestations of hemorrhagic stroke are focal neurological symptoms, sudden headache, nausea and impaired consciousness. The diagnosis is confirmed by the results of CT. Treatment consists of control of blood pressure, symptomatic therapy and, in some cases, surgical evacuation of hematomas.

Hemorrhages can occur in virtually any area of the brain - in the basal ganglia, brainstem, middle brain or cerebellum, as well as in the cerebral hemispheres. More often in clinical practice, hemorrhages in the basal ganglia, the brain, the cerebellum or the bridge are observed.

Intracerebral haemorrhage usually occurs when an atherosclerotically altered small-bore artery ruptures against a background of prolonged BP elevation. Intracerebral hemorrhages with arterial hypertension are single, extensive and catastrophic. Severe transient arterial hypertension and hemorrhage can provoke cocaine and other sympathomimetic drugs. Less common causes of hemorrhage are congenital aneurysms, arteriovenous or other vascular malformations, traumas, mycotic aneurysms, cerebral infarctions, primary or metastatic brain tumors, excessive anticoagulation therapy, immediate-type hypersensitivity reactions, blood diseases, vasculitis and other systemic diseases.

Often hemorrhages in the region of the brain poles are a consequence of amyloid angiopathy, which affects mainly people of senile age.

The formed hematoma exfoliates, squeezes and displaces adjacent brain tissue, disrupting its function. Large hematomas cause an increase in intracranial pressure. The pressure created by supratentorial hematoma and concomitant brain edema can lead to a transstan- torial cuffing of the brain that causes compression of the brainstem and often secondary hemorrhages in the middle brain and bridge. If blood breaks into the ventricular system (intraventricular hemorrhage), then acute hydrocephalus may develop. Cerebellar hematomas, increasing, can cause blockade of the ventricular system with the development of acute hydrocephalus and compression of the brainstem. Trauma of the brain, cerebral hemorrhage or variolium bridge, intraventricular hemorrhage, acute hydrocephalus or compression of the trunk are accompanied by a violation of consciousness, coma and can cause the death of the patient.

[1], [2],

Symptoms of an intracerebral hemorrhage

Intracerebral haemorrhage usually begins acutely, with a sudden headache, often after an intense load. Possible loss of consciousness within a few minutes, nausea, vomiting, delirium, partial or generalized convulsions. Neurological symptoms appear suddenly and increase. Extensive hemorrhages in the hemispheres cause hemiparesis, and in the posterior fossa - symptoms of damage to the cerebellum or trunk (paresis of the eye or ophthalmoplegia, stertorous respiration, pinpoint pupils, coma). Extensive hemorrhages in more than half of the patients result in a fatal outcome within a few days. The survivors return consciousness and the neurological deficit gradually regresses as the blood dissolves.

Less extensive hemorrhages can cause focal symptomatology without disturbance of consciousness, with mild headache and nausea or without them. They proceed as ischemic strokes, and the nature of the symptoms depends on the localization of the hemorrhage focus.

Diagnosis and treatment of intracerebral hemorrhage

About hemorrhage in the brain should be thought of with the sudden appearance of headache, focal neurological symptoms and impaired consciousness, especially in patients with risk factors. Intracerebral hemorrhage should be distinguished from ischemic stroke, subarachnoid hemorrhage and other causes of acute neurological disorders (convulsive syndrome, hypoglycemia).

Immediate CT and the determination of serum glucose level at the patient's bed are shown. In the absence of CT-signs of hemorrhage and the availability of clinical data in favor of subarachnoid hemorrhage, the patient undergoes lumbar puncture.

[3], [4], [5], [6], [7], [8]

Treatment of intracerebral hemorrhage

Treatment includes symptomatic therapy and control of general medical risk factors. Anticoagulants and antiplatelet drugs are contraindicated if the patient has taken anticoagulants earlier, their action should be neutralized by the introduction of freshly frozen plasma, vitamin K or by transfusion of platelet mass in the presence of indications. Arterial hypertension should be treated medically, only if the mean arterial pressure is more than 130 mm Hg. Or systolic blood pressure more than 185 mm Hg. Initially, intravenous nicardipine is administered at a dose of 5 mg / h; then the dose is increased by 2.5 mg / h every 5 minutes until a maximum dose of 15 mg / h is reached, in order to reduce systolic blood pressure by 10-15%. When the hemispheres of the cerebellum are more than 3 cm in diameter, causing brain dislocation, surgical emptying is an intervention in the vital indications. Early emptying of large hemispheric hematomas can also save the life of the patient, but they are characterized by frequent recurrences of bleeding, leading to an increase in neurological disorders. Indications for early emptying of deep hematomas are very rare, as surgical treatment is associated with high mortality and neurological complications. In a number of cases, neurological impairment is minimal due to the fact that intracerebral haemorrhage has a less destructive effect on the parenchyma of the brain than infarction.