Hemorrhagic stroke
The content of the article:
- Causes and risk factors
- Forms of the disease
- Disease stages
- Symptoms of hemorrhagic stroke
-
Diagnostics
Differential diagnosis
- Hemorrhagic stroke treatment
- Possible consequences of hemorrhagic stroke and complications
- Prognosis for hemorrhagic stroke
- Prevention
Hemorrhagic stroke is an acute violation of cerebral circulation, the development of which is caused by a spontaneous (non-traumatic) outpouring of blood directly into the brain tissue or under the meninges, manifested by neurological symptoms.
Source: likar.info
The problems of timely diagnosis, treatment and prevention of hemorrhagic stroke are becoming increasingly important all over the world every year due to the significantly increased incidence of the disease, a high percentage of disability and mortality. With all the achievements of modern medicine, 40% of patients die in the first month after a stroke and 5-10% during the next year.
Causes and risk factors
The development of hemorrhagic stroke is caused by rupture of a cerebral blood vessel, which most often occurs against the background of a significant and sharp increase in blood pressure. To such breaks predispose:
- vascular anomalies (congenital aneurysms, miliary aneurysms);
- destruction of the vascular wall caused by an inflammatory process (vasculitis) in it.
Much less often, the development of hemorrhagic stroke is caused by diapedesic, that is, bleeding that appears due to an increase in the permeability of the vascular wall, and not a violation of its integrity (10-15% of cases). The pathological mechanism of this form of bleeding is based on violations of vasomotor reactions, which first lead to a prolonged spasm of the blood vessel, which is replaced by its pronounced dilatation, i.e., expansion. This process is accompanied by an increase in the permeability of the vascular wall, as a result, through it, blood cells and plasma begin to sweat into the medulla.
The reasons leading to the development of hemorrhagic stroke are:
- arterial hypertension;
- cerebral aneurysms;
- arteriovenous malformation of the brain;
- vasculitis;
- amyloid angiopathy;
- hemorrhagic diathesis;
- systemic connective tissue diseases;
- therapy with anticoagulants and / or fibrinolytic agents;
- primary and metastatic brain tumors (in the process of growth, they grow into the walls of blood vessels, thereby causing their damage);
- carotid-cavernous fistula (pathological connection between the cavernous sinus and the internal carotid artery);
- encephalitis;
- hemorrhage in the pituitary gland;
- idiopathic subarachnoid hemorrhages (that is, those hemorrhages in the subarachnoid space of the brain, the cause of which cannot be established).
The following factors can enhance the damaging effect of the above reasons:
- overweight;
- long experience of smoking;
- alcohol abuse;
- drug addiction (especially the use of cocaine and amphetamines);
- lipid profile disorders;
- chronic intoxication;
- hard physical labor;
- prolonged nervous tension.
The focus of hemorrhage in 85% of cases is localized in the cerebral hemispheres, much less often - in the brain stem. However, such an atypical localization has an extremely unfavorable prognosis, since the respiratory and vasomotor centers, as well as the center of thermoregulation, are located in this area.
In those cases when the hematoma formed during hemorrhage is located in the thickness of the brain tissue, it disrupts the cerebrospinal fluid and venous outflow. As a result, cerebral edema increases, leading to an increase in intracranial pressure, displacement of brain structures and the development of vital dysfunctions.
Pouring out into the area of the basal cisterns, blood mixes with cerebrospinal fluid, which, in turn, causes neuronal death, hydrocephalus and spasm of blood vessels.
Forms of the disease
Depending on the location of the hemorrhage, the following types of hemorrhagic strokes are distinguished:
- subarachnoid - bleeding comes from the vessels of the arachnoid membrane, blood is poured into the subarachnoid space (i.e., the space between the arachnoid and soft membranes);
- intracerebral - the hematoma is located in the thickness of the tissue of the brain substance;
- ventricular - blood enters the aqueduct of the brain or ventricles;
- mixed - combines features of two or more types.
Source: medknsltant.com
The location of the hematoma in a certain anatomical region of the brain is accompanied by the appearance of specific symptoms, which in some cases allows determining its localization during the initial examination of the patient.
According to the etiology, hemorrhagic strokes are divided into two types:
- primary - hemorrhage occurs as a result of microangiopathy (thinning of the walls of blood vessels). During a hypertensive crisis, when blood pressure suddenly and significantly rises, the thinned section of the artery cannot withstand and ruptures;
- secondary - bleeding occurs as a result of rupture of acquired or congenital malformation of the cerebral vessels.
Depending on the location of the hematoma:
- lobar - the boundaries of the hematoma do not go beyond one of the cerebral hemispheres;
- lateral - hemorrhage occurs in the subcortical nuclei;
- medial - hemorrhage covers the thalamus;
- hematomas of the postcranial fossa;
- mixed.
Disease stages
Depending on the duration of the pathological process, the following stages of hemorrhagic stroke are distinguished:
- The sharpest. Lasts the first 24 hours after the onset of hemorrhage. It is critical that qualified medical care is provided during this period.
- Sharp. It starts one day after the stroke and lasts 3 weeks.
- Subacute. It starts from the 22nd day of the disease and lasts up to 3 months.
- Early recovery. From three months to six months.
- Late recovery. From six months to a year.
- The stage of long-term consequences. It begins a year after the stroke and lasts until its consequences disappear, in some cases for life.
Symptoms of hemorrhagic stroke
The clinical picture of hemorrhagic stroke usually develops against a background of significantly increased blood pressure, a strong emotional outburst, and physical overstrain.
In some cases, a stroke is preceded by a headache, vision of the surrounding objects in red, and flushing of the face. But most often the disease develops acutely (hence its old names - stroke, apoplexy).
The first clinical signs of hemorrhagic stroke are:
- severe headache, which patients describe as unbearable, the most severe in their life;
- hyperemia of the face;
- heart rhythm disturbances;
- noisy, hoarse, irregular breathing;
- violation of swallowing function;
- dilated pupils;
- noticeable pulsation of the blood vessels of the neck;
- nausea, repeated vomiting;
- paralysis of some muscle groups;
- high blood pressure;
- disorders of urination;
- impaired consciousness of varying severity (from mild lethargy to coma).
Signs of hemorrhagic stroke are growing very quickly. Deep and extensive hemorrhages lead to dislocation of the brain, which is manifested by the occurrence of seizures, loss of consciousness, and coma.
The severity of focal neurological symptoms in hemorrhagic stroke is determined by the location of the hematoma.
Extensive hemorrhage in the area of the basal nuclei of the brain is accompanied by impaired consciousness, collateral hemiparesis and hemianesthesia (i.e., insensitivity and partial paralysis of the right or left half of the body), turning the eyes towards the lesion.
Hematoma in the thalamus leads to loss of consciousness, collateral hemianesthesia and hemiparesis, limitation of vertical movement of the eyeballs, and the onset of Parino syndrome (miosis with a reduced pupil response to light).
With an intracerebellar hematoma, dynamic and static ataxia, disorders of consciousness develop, the functions of the cranial nerves fall out, paresis occurs and the movement of the eyeballs is disrupted.
Symptoms of a pons hemorrhage are:
- convergent squint;
- narrowing of the pupils to a point size while maintaining their reaction to light;
- quadriplegia (tetraplegia, paresis, or paralysis of all four limbs) with decerebral rigidity (increased tone of all muscle groups with a predominance of the tone of the extensor muscles);
- coma.
Symptoms of hemorrhagic stroke can be impaired speech, sensitivity, criticism, behavior, memory.
The most severe are the first 2-3 weeks of the disease, since during this period, cerebral edema develops and progresses. At this point, the addition of any somatic complications (pneumonia, exacerbation of chronic heart, liver or kidney diseases) to the symptoms of hemorrhagic stroke can cause death.
By the end of the third week, the patient's condition stabilizes, then begins to improve. There is a gradual regression of cerebral manifestations of hemorrhagic stroke, focal symptoms come to the fore, which further determines the severity of the patient's condition and the possibility of restoring the impaired functions.
Source: sostavkrovi.ru
Diagnostics
If a hemorrhagic stroke is suspected, magnetic resonance imaging or computed tomography of the brain is performed. This allows you to accurately determine the localization of the intracranial hematoma, its size, the presence of edema and dislocation of the brain. To control the involution of hematoma, MRI or CT is repeated at certain stages of treatment.
In addition, the following diagnostic methods are used:
- study of the blood coagulation system;
- determination of the content of drugs in the blood;
- angiography (performed in patients with normal blood pressure and when the hematoma is located in an atypical zone);
- lumbar puncture (performed if computed tomography is impossible).
Differential diagnosis
Hemorrhagic stroke is primarily differentiated from ischemic stroke. Ischemic stroke is characterized by a gradual onset, an increase in focal symptoms and preservation of consciousness. Hemorrhagic stroke begins acutely, with the development of cerebral symptoms. However, it is impossible to carry out differential diagnostics at the prehospital stage, relying only on the features of the clinical picture of the disease. Therefore, a patient with a preliminary diagnosis of "stroke" is admitted to the hospital, where the necessary studies (MRI, CT of the brain, lumbar puncture) are carried out, which will allow the correct final diagnosis to be made.
Concussions and bruises of the brain, as well as intracranial hematomas of traumatic origin, are much less common cause of impaired cerebral circulation. In the latter case, the development of hemiparesis is preceded by a light interval (the time from the moment of injury to the moment of onset of hemiparesis). In addition, anamnesis - an indication of traumatic brain injury - allows us to suggest a traumatic etiology of cerebral circulation disorder in this case.
Hemorrhagic stroke must be differentiated from hemorrhage in the tissue of a brain tumor, in particular, spongioblastoma multiforme. Suspicion of the neoplastic nature of the disease may arise if there are indications of prolonged headaches, changes in the patient's personality, which preceded the onset of hemiparesis, in the anamnesis.
In relatively rare cases, there is a need for the differential diagnosis of hemorrhagic stroke and the state after partial (Jacksonian) epileptic seizures.
Hemorrhagic stroke treatment
Patients with hemorrhagic stroke are admitted to the intensive care unit. Treatment begins with measures aimed at maintaining vital functions and preventing the development of complications. These include:
- adequate oxygenation (supply of humidified oxygen through a mask or nasal catheters, if necessary, transfer to mechanical ventilation);
- stabilization of blood pressure (both a significant increase and a sharp decrease in blood pressure are unacceptable);
- measures aimed at reducing cerebral edema and reducing intracranial pressure;
- prevention and therapy of infectious complications;
- constant medical supervision of the patient, as a sudden and rapid deterioration of his condition is possible.
Source: sovdok.ru
Medication for hemorrhagic stroke is selected by a neurologist and resuscitator.
To stop further hemorrhage in the brain tissue, the patient is prescribed drugs that reduce the permeability of the vascular walls, and hemostatics.
To reduce intracranial pressure, the use of osmotic diuretics and saluretics, colloidal solutions is indicated. Diuretic therapy requires regular monitoring of the concentration of electrolytes in the blood and timely correction of the water-electrolyte balance, if necessary.
In order to protect the brain from hypoxia and damage by free radicals, drugs with a pronounced antioxidant effect are used, for example, Mexidol.
Surgical treatment of hemorrhagic stroke is indicated when the diameter of the intracranial hematoma is over 3 cm.
With deep intracranial hematomas, early intervention is not justified, since it is accompanied by a deepening of neurological deficit and high postoperative mortality.
Lateral and lobar hematomas are removed by direct transcranial method. With a medial form of hemorrhagic stroke, it is possible to remove the hematoma with a more gentle stereotaxic method. The disadvantage of the stereotaxic method is the impossibility of performing a thorough hemostasis, therefore, after such operations, there is a risk of re-bleeding.
In some cases, in addition to removing the hematoma, the ventricles of the brain are also drained. Indications for extended surgical intervention are cerebellar hematoma, accompanied by occlusive dropsy of the brain and massive ventricular hemorrhages.
Possible consequences of hemorrhagic stroke and complications
The severity of the patient's condition after a hemorrhagic stroke, the degree of disability development and survival largely depend on the localization of the intracranial hematoma.
The formation of a hematoma in the area of the cerebral ventricles causes disturbances in CSF dynamics, as a result of which cerebral edema rapidly progresses, which, in turn, can lead to death already in the first hours of hemorrhage.
The most common type of disease is bleeding into the brain parenchyma. The blood soaks into the nerve tissue and causes massive neuronal death. The consequences of a hemorrhagic stroke in this case are determined not only by the localization of the pathological focus, but also by its size.
After extensive hemorrhage in the late period, the following complications are observed:
- limb movement disorders, insufficient coordination;
- lack of sensitivity in the affected areas of the body;
- swallowing disorders;
- dysfunction of the pelvic organs;
- difficulties in the process of perception, processing and memorization of information, loss or decrease in the ability to generalize, logical thinking;
- violations of speech, counting, writing;
- various disorders of the psyche and behavioral reactions (disorientation in space, anxiety, detachment, suspiciousness, aggressiveness).
Prognosis for hemorrhagic stroke
In general, the prognosis for hemorrhagic stroke is poor. According to various authors, the mortality rate reaches 50–70%. Increasing edema and dislocation of the brain, recurrent hemorrhage are fatal. More than 65% of surviving patients become disabled. The factors that complicate the prognosis of the disease are:
- elderly age;
- diseases of the cardiovascular system;
- hemorrhage in the ventricles of the brain;
- localization of hematoma in the brain stem.
The most unfavorable prognosis for hemorrhagic stroke in terms of restoration of mental, sensory and motor function is observed with extensive hematomas, damage to the deep structures of the brain (limbic system, subcortical nuclei), cerebellar tissue. Hemorrhage in the brain stem (the region of the vasomotor and respiratory centers), even with timely initiation of intensive therapy, leads to the rapid death of patients.
Most stroke survivors remain immobilized and lose the ability to self-care. As a result, they often develop congestive pathology - bedsores, vein thrombosis of the lower extremities, which, in turn, leads to the development of thromboembolic complications, among which the most dangerous is PE (pulmonary embolism). In addition, urinary tract infections, congestive pneumonia, sepsis, and chronic heart failure often develop. This further worsens the quality of life of patients, and also becomes the cause of deaths in the early and late long-term period.
Prevention
The main measure for the prevention of hemorrhagic stroke is adequate and timely treatment of arterial hypertension and other diseases accompanied by an increase in blood pressure:
- thyrotoxicosis;
- hormone-producing adrenal adenoma;
- pheochromocytoma;
- atherosclerosis;
- vegetative vascular dystonia;
- kidney disease (glomerulonephritis, abnormalities in the structure of the renal arteries, renal failure).
It is equally important to lead a healthy lifestyle, which includes:
- quitting smoking and alcohol abuse;
- regular, but not excessive physical activity;
- daily walks in the fresh air;
- proper nutrition;
- normalization of body weight.
A healthy lifestyle significantly reduces the risk of atherosclerosis and hypertension, as a result of which the risk of intracranial hemorrhage is also reduced.
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Elena Minkina Doctor anesthesiologist-resuscitator About the author
Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.
Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
