Intracerebral hemorrhage

Intracerebral hemorrhage is a localized bleeding from blood vessels within the brain parenchyma. 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 CT. Treatment consists of blood pressure monitoring, 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, midbrain or cerebellum, as well as in the cerebral hemispheres. More often in clinical practice, hemorrhages are observed in the basal ganglia, lobes of the brain, cerebellum or pons.

Intracerebral hemorrhage usually occurs when an atherosclerotically altered small-caliber artery ruptures against the background of a long-term increase in blood pressure. Intracerebral hemorrhages in arterial hypertension can be isolated, extensive, and catastrophic. Severe transient arterial hypertension and hemorrhage can be provoked by cocaine and other sympathomimetic drugs. Less common causes of hemorrhage include congenital aneurysms, arteriovenous or other vascular malformations, trauma, mycotic aneurysms, cerebral infarctions, primary or metastatic brain tumors, excessive anticoagulation therapy, immediate 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 mainly affects elderly people.

The resulting hematoma stratifies, compresses and displaces the adjacent brain tissue, disrupting its function. Large hematomas cause increased intracranial pressure. The pressure created by the supratentorial hematoma and accompanying cerebral edema can lead to transtentorial brain herniation, causing compression of the brainstem and often secondary hemorrhages in the midbrain and pons. If blood breaks through into the ventricular system (intraventricular hemorrhage), acute hydrocephalus can develop. Cerebellar hematomas, enlarging, can cause blockade of the ventricular system with the development of acute hydrocephalus and compression of the brainstem. Brain herniation, hemorrhage into the midbrain or pons, intraventricular hemorrhage, acute hydrocephalus or compression of the brainstem are accompanied by impaired consciousness, coma and can cause death of the patient.

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Symptoms of intracerebral hemorrhage

Intracerebral hemorrhage usually begins acutely, with a sudden headache, often after intense exertion. Loss of consciousness within a few minutes, nausea, vomiting, delirium, partial or generalized seizures are possible. 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 brainstem (gaze paresis or ophthalmoplegia, stertorous breathing, pinpoint pupils, coma). Extensive hemorrhages in more than half of patients end in death within a few days. In survivors, consciousness returns and the neurological deficit gradually regresses as the blood is absorbed.

Less extensive hemorrhages may cause focal symptoms without loss of consciousness, with or without moderate headache and nausea. They occur as ischemic strokes, and the nature of the symptoms depends on the location of the hemorrhage.

Diagnosis and treatment of intracerebral hemorrhage

Cerebral hemorrhage should be considered in the case of sudden 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 (convulsions, hypoglycemia).

Immediate CT and bedside serum glucose measurements are indicated. If there is no CT evidence of hemorrhage and clinical evidence of subarachnoid hemorrhage is present, the patient undergoes lumbar puncture.

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Treatment of intracerebral hemorrhage

Treatment includes symptomatic therapy and control of general medical risk factors. Anticoagulants and antiplatelet drugs are contraindicated in patients with previous anticoagulant use and should be reversed with fresh frozen plasma, vitamin K, or platelet transfusion when indicated. Hypertension should be treated medically only if mean arterial pressure is greater than 130 mmHg or systolic pressure is greater than 185 mmHg. Nicardipine is administered intravenously initially at a dose of 5 mg/h; the dose is then increased by 2.5 mg/h every 5 minutes to a maximum dose of 15 mg/h, in order to reduce systolic blood pressure by 10-15%. In case of a cerebellar hematoma greater than 3 cm in diameter, causing brain dislocation, surgical drainage is an intervention for vital indications. Early drainage of large hemispheric hematomas can also save the patient's life, but they are characterized by frequent relapses of bleeding, leading to an increase in neurological disorders. Indications for early drainage of deep hematomas are very rare, since surgical treatment is associated with high mortality and neurological complications. In some cases, neurological disorders are minimal due to the fact that intracerebral hemorrhage has a less destructive effect on the brain parenchyma than infarction.