What Is an Intraparenchymal Hemorrhage?

Cerebral hemorrhage refers to bleeding caused by non-traumatic cerebral parenchymal rupture of blood vessels, accounting for 20% to 30% of all strokes, and the mortality rate in the acute phase is 30% to 40%. The cause is mainly related to cerebrovascular disease, that is, it is closely related to hyperlipidemia, diabetes, hypertension, aging of blood vessels, smoking and so on. Patients with cerebral hemorrhage often have sudden onset due to emotional excitement and exertion. The early mortality rate is very high. Most of the survivors have sequelae such as dyskinesia, cognitive impairment, and speech and swallowing disorders.

Basic Information

nickname

Cerebral hemorrhage

English name

cerebral hemorrhage

Visiting department

Neurology

Multiple groups

Middle-aged and elderly, hypertension patients, cerebrovascular malformations

Common causes

Hypertension with arteriosclerosis, microaneurysm or microhemangioma rupture

Common symptoms

General symptoms include headache, vomiting, lethargy, and coma

Causes of cerebral hemorrhage

Common causes are hypertension with arteriolar sclerosis, microaneurysms, or microhemangiomas. Others include cerebrovascular malformations, meningeal arteriovenous malformations, amyloid cerebrovascular disease, cystic hemangioma, intracranial venous thrombosis, specific arteritis, Fungal arteritis, moyamoya disease and arterial anatomical variation, vasculitis, and tumor.

In addition, hematological factors include anticoagulation, antiplatelet or thrombolytic therapy, Haemophilus infections, leukemia, thrombotic thrombocytopenia, and intracranial tumors, alcoholism, and sympathetic nerve stimulation drugs.

Excessive exertion, climate change, bad habits (smoking, alcoholism, excessive salt, and weight), fluctuations in blood pressure, emotional excitement, and overwork are the triggering factors.

Clinical manifestations of cerebral hemorrhage

Hypertensive intracerebral hemorrhage often occurs in the age of 50 to 70 years old, slightly more men, easy to occur in winter and spring, usually onset during activities and emotional excitement, usually without warning, bleeding in most patients with headache and severe, vomiting, bleeding after bleeding Blood pressure rises significantly, and clinical symptoms often reach a peak in minutes to hours. The clinical symptoms and signs vary depending on the bleeding site and the amount of bleeding. Hemiplegia caused by hemorrhage in the basal nucleus, thalamus and internal capsule is a common early symptom; a few cases appear Seizures, often focal; severe cases quickly turn into confusion or coma.

1. Movement and language barriers

Dyskinesia is more common in hemiplegia; speech disorders are mainly manifested by aphasia and ambiguity.

Vomiting

Vomiting in about half of patients may be related to increased intracranial pressure during cerebral hemorrhage, dizziness, and blood irritation of the meninges.

3. Disorder of consciousness

Appears as drowsiness or coma, the degree is related to the location, amount and speed of cerebral hemorrhage. A large amount of bleeding in a short time in the deep part of the brain, and most of them will have a disturbance of consciousness.

4. Eye symptoms

Pupil inequality often occurs in patients with cerebral hernia due to increased intracranial pressure; there may also be hemianopia and impaired eye movements. Patients with cerebral hemorrhage often stare at the bleeding side of the brain (gaze paralysis) in the acute phase.

5. headache dizziness

Headache is the first symptom of intracerebral hemorrhage, often on the head on one side of the hemorrhage; with increased intracranial pressure, pain can progress to the entire head. Dizziness is often accompanied by headaches, especially when the cerebellum and brain stem are bleeding.

Cerebral hemorrhage examination

(I) Laboratory inspection

Cerebrospinal fluid examination

Clinic spinal fluid examination is generally not performed to prevent cerebral hernia in patients with clear diagnosis, but lumbar puncture is still of certain diagnostic value when brain CT scan or brain MRI examination is performed unconditionally. After cerebral hemorrhage, intracranial pressure is generally lower due to edema of brain tissue. High, 80% of patients have bloody or yellow cerebrospinal fluid after 6 hours of onset, but the possibility of cerebral hemorrhage cannot be completely ruled out when lumbar penetrating cerebrospinal fluid is clear. Dehydration agents should be given before surgery to reduce intracranial pressure, increased intracranial pressure or brain When a hernia is possible, a lumbar puncture should be contraindicated.

2. Blood routine, urine routine and blood sugar

Routine blood tests in severe patients can show an increase in white blood cells, which can be positive for urine glucose and proteinuria. The increase in blood glucose in the acute phase of cerebral hemorrhage is caused by stress. The increase in blood glucose not only directly reflects the body's metabolic state, but also reflects the severity of the disease. The higher the blood sugar, the higher the incidence of complications such as stress ulcers, cerebral hernias, metabolic acidosis, and azotemia, and the worse the prognosis.

(Two) neuroimaging examination

1.CT examination

A cranial CT scan can clearly show the bleeding site, the amount of bleeding, the shape of the hematoma, whether it has broken into the ventricle, and whether there is a low-density edema band around the hematoma and the space effect. The lesions were mostly round or oval-shaped uniform high-density areas, with clear boundaries. When there was a large amount of hemorrhage in the ventricle, they were mostly high-density molds, and the ventricles were enlarged. After 1 week, there was a ring-shaped enhancement around the hematoma, and the hematoma showed low density or cystic change after absorption. Dynamic CT examination can also evaluate the progress of bleeding.

2.MRI and MRA examination

CT scans are better than structural scans for detecting structural abnormalities, detecting bleeding lesions in the brainstem and cerebellum, and monitoring the evolution of cerebral hemorrhage, and are not as good as CT for acute cerebral hemorrhage.

3. Digital Subtraction Cerebral Angiography (DSA)

Cerebral aneurysms, cerebral arteriovenous malformations, Moyamoya disease, and vasculitis can be detected.

4. ECG examination

Patients with cerebrovascular disease may have changes in cardiac function and vascular function because of brain-heart syndrome or the heart itself: conduction block such as prolonged PR interval, nodular rhythm or atrioventricular separation, arrhythmia, atrial Or ventricular premature contraction, ST segment prolongation, decline, T wave changes, ECG changes of other pseudo-myocardial infarction.

5. Transcranial Doppler (TCD) examination

It is helpful to judge intracranial hypertension and brain death. When hematoma is more than 25ml, TCD shows asymmetric changes in intracranial hemodynamics, indicating asymmetry of intracranial pressure. The pulsatility index can reflect the asymmetry of intracranial pressure more than the average blood flow velocity. .

(3) Other inspections

Including, blood biochemistry, coagulation function and chest X-ray examination. Peripheral leukocytes and urea nitrogen levels may temporarily increase, and abnormal thromboplastin time and partial thromboplastin time suggest clotting dysfunction.

Cerebral hemorrhage diagnosis

Middle-aged and elderly patients with sudden onset during activity or emotional agitation, symptoms of focal neurological deficits, and symptoms of cranial hypertension such as headache and vomiting should consider the possibility of cerebral hemorrhage. Combined with skull CT examination, a rapid and clear diagnosis can be made. Cerebral hemorrhage diagnosis based on:

1. Most are over 50 years old and have a long history of hypertension arteriosclerosis.

2. Sudden onset of physical activity or emotional agitation, symptoms such as headache, vomiting, and disturbance of consciousness.

3. Onset is rapid, and symptoms of limb dysfunction and increased intracranial pressure occur within minutes or hours.

4. Physical examination showed signs of nervous system localization.

5. Brain CT scan showed that the hematoma in the brain showed a high-density area. Hematomas with a diameter of more than 1.5cm can be accurately displayed. It can determine the bleeding site, the size of the hematoma, whether it has broken into the ventricle, and whether there is cerebral edema and cerebral hernia formation. , The diagnosis is based on the brain CT scan to see the bleeding lesions, CT almost 100% of the diagnosis of cerebral hemorrhage.

6. Bloody cerebrospinal fluid can be seen through lumbar puncture. At present, cerebral hemorrhage is rarely diagnosed based on cerebrospinal fluid.

Cerebral hemorrhage treatment

Treatment principles include quiet bed rest, dehydration and lowering of intracranial pressure, adjustment of blood pressure, prevention of continued bleeding, and strengthening of nursing to maintain life functions. Prevention and treatment of complications to save lives, reduce mortality, disability and reduce recurrence.

1. Generally should rest in bed for 2 to 4 weeks, keep quiet, avoid emotional excitement and elevated blood pressure. Closely observe vital signs such as temperature, pulse, breathing and blood pressure, and pay attention to changes in pupils and consciousness.

2. Keep the airway unobstructed, and clean up airway secretions or inhalation. Tracheal intubation or incision should be performed in time if necessary; those with conscious disturbance and gastrointestinal bleeding should fast for 24 to 48 hours, and empty the stomach contents if necessary.

3. Water and electrolyte balance and nutrition, daily fluid volume can be calculated according to urine volume + 500ml, if there is high fever, sweating, vomiting, maintain the central venous pressure at 5-12mmHg level. Pay attention to prevent water and electrolyte disorders, so as not to aggravate brain edema. Daily sodium, potassium, sugar, calories, if necessary, fat emulsion injection (fat milk), human serum albumin, amino acids or energy mixtures.

4. Adjust blood sugar. Those who are too high or too low should be corrected in time to maintain blood sugar levels between 6 and 9 mmol / L.

5. Patients with obvious headache and excessive irritability may be appropriately given sedative pain; constipation may choose laxatives.

6. Reduce intracranial pressure. Cerebral edema reaches its peak in about 48 hours after intracerebral hemorrhage, and gradually subsides after maintaining for 3 to 5 days, which can last for 2 to 3 weeks or longer. Cerebral edema can increase intracranial pressure and cause the formation of cerebral hernia, which is the main factor affecting the mortality and functional recovery of cerebral hemorrhage. Active control of cerebral edema and reduction of intracranial pressure are important links in the treatment of acute phase of cerebral hemorrhage.

7. Generally speaking, when the condition is critical, the intracranial pressure is too high, and a cerebral hernia appears. When conservative medical treatment is not effective, surgical treatment should be performed in time.

8. Rehabilitation treatment. As long as the patient's vital signs are stable and the condition no longer progresses after cerebral hemorrhage, rehabilitation treatment should be carried out as soon as possible. Early staged comprehensive rehabilitation is beneficial to restore the patient's nerve function and improve the quality of life.