Hemorrhagic stroke of the brain: causes, symptoms and treatment

Hemorrhagic stroke is a hemorrhage into the substance of the brain or under the membranes of the brain. This disease refers to acute disorders of cerebral circulation. Morbidity and mortality from acute disorders of cerebral circulation in Russia in most regions takes a leading position. Mortality with hemorrhagic stroke is 75-90%. Every one and a half minutes a Russian develops a stroke.

These indicators speak for themselves: the urgency of the problem is beyond doubt. Let us examine in more detail what kind of illness it is, what causes it, what are the main reasons for it. Also, recall that appoint a treatment should only a doctor of sufficient skill.

Causes

Among the most common causes are:

• in the first place is hypertension (can be combined with atherosclerosis) - i.e. high blood pressure;
• symptomatic arterial hypertension (caused by kidney disease, endocrine organs);
instagram viewer
• systemic vascular diseases of allergic and infectious-allergic nature (systemic lupus erythematosus, nodular periarteritis, vasculitis, arteritis, etc.);
• aneurysms of cerebral vessels, malformation (congenital, rarely acquired pathological connection between veins and arteries);
• hemorrhagic diathesis (coagulopathy);
• brain trauma;
• malignant tumors;
• sepsis;
• uremia.

Hemorrhage occurs by different mechanisms.

In one case, with an increase in blood pressure (usually sharp, sudden and high digits), a vessel is torn, the wall of which is thinned by a pathological process, and blood is massively poured into surrounding tissues with the formation of an intracerebral hematoma.

Hematoma is a cavity with blood, it is formed in a matter of minutes. With this type of hemorrhagic stroke, often a breakthrough occurs in the ventricles of the brain or in the subarachnoid space. A consequence of this may be a violation of venous outflow, liquor circulation, edema of the brain, increased intracranial pressure. And this, in turn, leads to dislocation (displacement) of the brain, compression of important structures of the brain stem, responsible for the regulation of breathing and cardiac activity. All these dangerous complications of a hemorrhagic stroke can lead to a lethal outcome, which explains the severity of the process.

In another case, slowly and gradually, due to one of the diseases described above, the permeability of the vascular wall changes, the blood "impregnates" itself with the adjacent tissue of the brain. Then these blood-soaked foci merge. This type of hemorrhagic stroke was called diapedesis hemorrhage. Increase in blood pressure in this case can also serve as a trigger mechanism.

Symptoms

There are two types of hemorrhagic stroke: parenchymal hemorrhage (ie, the thickness of the brain tissue) and subarachnoid hemorrhage (ie, under the shell of the brain).

Parenchymal hemorrhage

Parenchymal hemorrhage can be accompanied by a violation of consciousness.

More often the disease affects people of working age (40-60 years). The beginning is usually sudden. Unexpectedly, against a background of some provoking factor (physical, emotional tension, alcohol consumption), there is a sharp headache. Patients call it "sudden stroke." Sometimes, simultaneously with pain, consciousness is immediately lost and the patient falls. The depth of the disturbance of consciousness is different: from stunning to coma. In some cases, a stroke of blood is felt before the stroke, the objects are seen in red or "through the fog".

Headache is often accompanied by vomiting, psychomotor agitation. Skin covers are hyperemic (filled with blood), often marked profuse sweating, pulse is tense, tachycardia, blood pressure is raised to 180-200 mm Hg. Art. and higher. Breath is disturbed: it becomes frequent, snoring, with a labored exhalation or inhalation. There may be pathological types of breathing: Cheyne-Stokes, Kussmaul.
Symptoms that are characteristic of a disease such as meningitis appear. With parenchymal hemorrhage, they are moderately expressed, occasionally absent.

Perhaps the beginning in the form of an epileptic fit.

Simultaneously with cerebral, vegetative, meningeal symptoms, so-called focal symptoms also arise. This symptomatology indicates the localization of hemorrhage. Each area of ​​the brain is responsible for a specific function. These areas are studied, and the violation of the functions allows you to determine the location of the lesion, which is used in topical diagnostics.

There are three types of hemorrhage.

1. Hemispheric hemorrhage.There is hemiparesis (weakness in one half of the body - left or right) or hemiplegia (complete absence of muscle strength) on the opposite side of the hemorrhage. In the same limbs, sensitivity is lost, muscle tone changes (it may decrease or may increase). Develops a paralysis of the eye with the removal of the eyes in the direction opposite to the paralyzed limbs. This symptom is said - "the patient is looking at the hearth." Those. eyes do not look straight ahead, but are turned to the left or to the right. If the patient's consciousness is not disturbed, one can detect a speech disorder - aphasia (can be violated as an understanding of speech, so and its reproduction), violation of the fields of vision - hemianopsia (the patient does not see the left or right half of the image). The ability to read and count can be impaired. Perhaps misunderstanding of the patient's condition: the patient denies the presence of weakness in the limbs, although it can not move them at all. If the patient's consciousness is lost, then during the initial examination it is possible to identify symptoms that may suggest a stroke: inflation of the cheek as you exhale (the "sail" symptom) on the side of paralysis, the turn of the foot outward on the side of the paralysis, the symptom of the "whip" (the paralyzed limbs fall faster when bending), low reflexes on the paralyzed side, the presence of specific pathological symptoms (Babinsky, Rossolimo, Zhukovsky, Gordon, Poussep, and others. - when examined by a neuropathologist).
2. Hemorrhage in the trunk of the brain.Symptoms of a lesion of the cranial nerves appear (the face changes, the convergent or divergent strabism appears, the tongue deviates from the middle line, there is a nasal voice, a person can choke with food, etc.), heart activity and breathing are immediately disturbed. A characteristic feature is the so-called alternating syndromes: on one side of the face there are signs of the defeat of some the cranial nerve, and on the other side of the body, hemiparesis and / or a sensitivity disorder is detected. It is possible tetraparesis - i.e. paralysis of all four limbs. With a hemorrhage, a paralysis of the eye develops in the bridge of the brain with a turn of the eyes toward the paralyzed limbs: "the patient turns away from the hearth." There may be either narrowing of the pupils, or widening, immovability of the gaze in general, or "floating movements of the eyeballs," possibly a violation swallowing, cerebellar symptoms: marked instability and shakiness, the patient may miss when trying to take an object. Definitely, the symptomatology depends on which part of the brain stem is covered by the hemorrhage.
3. Hemorrhage in the cerebellum.It appears dizzy with a sense of rotation of surrounding objects, nausea, repeated vomiting, which does not bring relief. Patients complain of pain in the nape of the neck, sometimes pain in the neck. Practically always immediately there are meningeal symptoms, especially clearly expressed stiff neck muscles. A diffuse loss of muscle tone develops up to atony (complete absence of muscle tonus), cerebellar ataxia, nystagmus. Nystagmus is the involuntary movements of eyeballs of an oscillatory nature. Patients can not support the pose, stagger, like drunk. Perhaps the appearance of chanted speech: intermittent, jerky, as if divided into separate fragments.

With large hematomas (whose volume exceeds 30 cubic centimeters), located deep in the brain tissue, a breakthrough of blood to the ventricular system of the brain is possible. Also, hemorrhages in the brain stem and cerebellum tend to break blood into the ventricles of the brain. This condition threatens the life of the patient. Clinically, this is accompanied by a sharp deterioration in the general condition, the instant development of coma. Appears characteristic trait, grometonia (pseudoconcus). This term refers to the periodic increase in muscle tone in the limbs lasting from a few seconds to several minutes. Vitally important functions are violated: breathing and cardiac activity. Usually very quickly these symptoms develop a fatal outcome.

There are several variants of the development of hemorrhage in the brain in terms of the rate of development of the pathological process:

• sharp - most often. In a few seconds or minutes, neurological symptoms develop. It is accompanied by the breakthrough of blood into the ventricular system of the brain or the development of edema of the brain with dislocation and compression of the brain structures. The likelihood of a lethal outcome is high;
• subacute - the beginning also within a few minutes, then the clinical manifestations somewhat stabilize, there are no symptoms of wedging and dislocation. After 2-3 days, edema of the brain is formed or repeated hemorrhages are possible, which is accompanied by worsening of the condition;
• Chronic - a rare option, mainly with diapedesis impregnation.

Subarachnoid haemorrhage

Headache with subarachnoid hemorrhage is compared with a "dagger blow".

This type of hemorrhagic stroke develops with the penetration of blood into the subarachnoid space. It is located between the membranes of the brain. Normally filled with cerebrospinal fluid (cerebrospinal fluid).

This type of hemorrhage is typical for young people (25-40 years old) and even children, since the most frequent cause of it is an aneurysm of cerebral vessels.

The factors that provoke subarachnoid hemorrhage include:

• sharp and rapid increase in blood pressure;
• sudden physical stress (lifting of gravity, act of defecation with constipation, severe cough, sexual intercourse);
• psycho-emotional tension (both negative and positive emotions);
• marked worsening of venous outflow at night in patients with a pronounced atherosclerotic lesion of the brain vessels;
• rapidly advancing decompensation of blood diseases;
• craniocerebral trauma.

As a rule, the onset of the disease is acute. There is a sharp headache ("punch in the back of the head"), nausea and vomiting, an epileptic attack may develop. Usually, before the development of hemorrhage, the patient does not bother at all. Rarely may be harbingers, but they are nonspecific: headache, pain in the eye, flies flies before the eyes, noise in the head, dizziness.

A very characteristic symptom for this type of hemorrhagic stroke is psychomotor agitation. It appears simultaneously with a hemorrhage and lasts for several days, then the patients do not remember this period well. In the first hours there aremeningeal symptoms, they are more pronounced than in parenchymal hemorrhage: hyperesthesia of the sensory organs and skin, stiff neck muscles, symptoms of Kernig, Brudzinsky, Kerer, Bekhterev, and others. Body temperature rises to 38-39 ° C.

But focal neurological signs are absent, as the hemorrhage does not directly capture the brain tissue. This subarachnoid hemorrhage clinically differs from the parenchymal hemorrhage.

Subarachnoid hemorrhage is accompanied by the development of reflex spasm of blood vessels. Typically, angiospasm occurs on the 2-3 days, 7-10 days, and, rarely, 14-21 days. This leads to a worsening of the patient's condition and the appearance of focal symptoms.

Blood clots in the subarachnoid space can cover the outflow pathway of the cerebrospinal fluid (they act as a kind of tampons), which can lead to occlusive hydrocephalus, that is, the accumulation of an excessive amount of cerebrospinal fluid from the meninges. This is life-threatening condition, as it also leads to the dislocation of brain structures with possible fatal outcome. In later terms, blood clots in the cerebrospinal fluid can lead to the formation of skin adhesions The brain with the underlying tissue of the brain involving the vessels, craniocerebral nerves (leptomeningitis).

Very often a repeated subarachnoid hemorrhage develops.

Diagnostics

To establish the diagnosis of the patient, if the condition allows, carefully collect complaints and anamnesis, conduct a neurological examination. Usually this is enough to establish the presence of a disorder of cerebral circulation. However, in order to confirm the hemorrhagic nature of the process, additional examinations are needed. These include CT or MRI of the brain, puncture of the cerebrospinal fluid at the lumbar level. In addition, such patients are shown the entire minimal complex of diagnostic tests: ECG, laboratory tests of blood, urine, etc. The list of researches can differ, is selected individually.

Treatment

Treatment of hemorrhagic stroke is divided into 2 types: basic and specific.
Basis is aimed at stabilizing and maintaining vital functions:

• treatment of breathing disorders: after determining the gas composition of the blood, correction of these parameters is carried out. Oxygen inhalations are shown. If breathing is significantly impaired, intubation of the trachea and artificial ventilation may be possible;
• normalization of the functions of the cardiovascular system: this includes the correction of blood pressure and heart rhythm. For patients with hemorrhagic stroke, blood pressure should be maintained at no more than 150/90 mm Hg. To reduce blood pressure, metoprolol, captopril, clonidine, magnesium sulfate (ie, short-acting drugs) can be used. If the arterial pressure is lowered, then infusion therapy is carried out using physiological solution of sodium chloride, rheopolyglucin, hydroxyethyl starch, dopamine, norepinephrine, dobutamine. If cardiac rhythm disturbances are detected, a consultation by the cardiologist and the appointment of appropriate medications are necessary;
• reduction of water-electrolyte balance to the norm: maintenance of rheological indicators at the proper level, avoidance of a decrease in the volume of circulating blood, prevention of cerebral edema;
• decrease in body temperature: if the temperature rises above 37.5 ° C, use paracetamol, ibuprofen, analgin with dimedrol;
• normalization of blood glucose levels: if the index is more than 10 mmol / l (diabetes mellitus), then use insulin. If the glucose concentration is less than 2.8 mmol / l, then 10% glucose solution is injected intravenously;
• adequate nutrition: if the patient is conscious and able to eat, then the food is shown to be high in calories. If the patient is in a coma, then special intravenous solutions are indicated. If there are violations of swallowing, the patient is put nasogastric tube and fed through it (prevention of aspiration pneumonia);
• treatment of edema of the brain: this is facilitated by adequate ventilation of the lungs. From medications use corticosteroids (dexamethasone), osmotic diuretics (mannitol) in combination with lasix or furosemide, L-lysine escinate, magnesium sulfate. For the prevention of edema of the brain, it is necessary that the head and upper part of the patient's body be constantly raised by 20-30 °;
• treatment of complications: because patients with hemorrhagic stroke - this is a severe hospital patient, forced to considerable time to comply with bed regime, they have a higher risk of pneumonia, deep vein thrombosis, pulmonary embolism, urinary tract infections, pressure sores. All these states require a differentiated approach to treatment.

The specific treatment of hemorrhagic stroke is both medication and surgical intervention. Operations are shown to patients with hemorrhage in the cerebellum, with subarachnoid hemorrhage due to aneurysm rupture. In other cases, the question of surgical treatment is decided individually.

Medication:

• stimulation of hemostasis: dicycin, aminocaproic acid, tranexamic acid;
• the introduction of antifoam preparations: countercrital, gordoks;
• treatment of vasospasm resulting in decreased blood flow (vasospasm) with subarachnoid hemorrhage: nimodipine, magnesium sulfate is used.

Many aspects of treating patients with hemorrhagic strokes are discussed by doctors to this day. Medicine continues to search for effective remedies and methods for eliminating such a common pathology of the brain, as a hemorrhagic stroke.

Video about the stroke, its causes and consequences