Hemorrhagic Stroke - Causes, Symptoms And Consequences, Treatment And Prognosis

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Hemorrhagic stroke

Hemorrhagic stroke is diagnosed in 7-8% of patients with neuropathology. The disease is characterized by severe pathogenesis with mortality up to 50% and disability up to 80%.

Timely identification of the first signs of the disease and quick delivery of the patient to the clinic by about 15% increases the likelihood of a favorable outcome of hemorrhagic stroke.

What is Hemorrhagic Stroke?

The nosological form includes two terms: "hemorrhage" is a hemorrhage, and the word "stroke" means an infarction (ischemic necrosis) of a part of the brain.

Hemorrhagic stroke is a hypertensive hemorrhage in the parenchyma of the brain, accompanied by acute disturbance of cerebral circulation, loss of functions of the affected area, development of pathogenesis in the nucleus and perifocal (around the nucleus) zone. The disease is manifested by general and local neurological symptoms.

Hemorrhagic stroke is mainly a complication of hypertension.

More severe pathogenesis in comparison with ischemic stroke is associated with the cumulative effect of:

• Hemorrhage in the brain tissue, compression of the surrounding vessels;
• Inflammatory necrotic processes in the core of a stroke;
• Dystrophic and inflammatory processes at the periphery of the nucleus.

There are two main types of cerebral hemorrhages of different origins:

• Hemorrhagic stroke (GI) - hemorrhage / permeation of the brain parenchyma;
• Subarachnoid hemorrhages (SAH) - hemorrhages in the cerebral cortex of a non-traumatic nature, in no way associated with vascular malformations.

At the initial observation of the patient, hemorrhages are diagnosed as intracerebral hematoma (IMH). Differentiation is carried out in the clinic based on the results of instrumental (MRI, CT) visualization of the structures of the brain and cranium.

There are several options for the localization of cerebral hemorrhages, namely:

• Putamenal lateral (lateral) - on the side of the inner capsule;
• Subcortical (subcortical);
• Lobar - in the first lobe of the brain;
• Thalamic (medial) - located towards the center of the inner capsule;
• Mixed;
• Cerebellar;
• Stem (pavement).

Putamenal strokes are widespread - they account for up to half of all types of hemorrhagic strokes, subcortical and thalamic strokes are less common - about 15% for each type. Hemorrhages in the cerebellum and brain stem are much less common - up to 8% of all strokes.

The most severe lesions of the body are massive hemorrhages in the hemisphere, trunk or cerebellum of the brain. Hemorrhagic strokes are more likely to develop in men prone to hypertension and have bad habits. The likelihood of cerebral hemorrhage increases with age.

In women aged 30-40 years, the risk of hemorrhagic stroke is associated with childbirth and the postpartum period and is due to the layering of massive birth / postpartum bleeding on violations of the cardiovascular system.

Content:

• Symptoms of hemorrhagic stroke
• Causes of hemorrhagic stroke
• Coma with hemorrhagic stroke
• Passing a medical and social examination
• Hemorrhagic stroke treatment

Symptoms of hemorrhagic stroke

More than a hundred different clinical symptoms of hemorrhagic stroke are known; transformation of an ischemic stroke into a hemorrhagic one is also possible. This greatly complicates the differential diagnosis of the disease. Primary signs indicating a stroke should be determined by the description of the patient's sensations, speech changes, severe headache, impaired consciousness.

Also use simple tests to detect strokes (here)

Possible precursors of hemorrhagic stroke

• Tingling, numbness of half of the face;
• Severe sharp pain in the eyes, partial loss of vision;
• Sudden loss of balance;
• Difficulty understanding speech.

They appear shortly before the attack, but they are not mandatory signs of GI.

For hemorrhagic stroke, a sudden onset of the disease is more characteristic. On the eve or just before an attack, stress is possible in the form of physical and / or emotional stress.

Attention! Any of the following signs, as well as other symptoms indicating a sudden disorder of vital functions, is a reason for an urgent call for an ambulance (the algorithm for calling an ambulance is here).

During a telephone conversation with the operator, it is necessary to clearly describe the signs of a stroke found in the patient.

Signs of a hemorrhagic stroke in a conscious person:

• Headache that is growing rapidly;
• Nausea, vomiting;
• Heart palpitations;
• Intolerance to bright light, "circles" and "midges" before the eyes;
• paresis, Paralysis of arms, legs, facial muscles;
• Difficulty speaking.

Signs of hemorrhagic stroke in an unconscious person:

Do not try to bring the patient back to consciousness!

There are four distinct stages of consciousness regression. They can be independently defined as follows:

• Stunning - an incomprehensible look of the patient, weak response to others;
• Somnolence - resembles a dream with open eyes, the gaze is directed into space;
• Stupor - resembles a deep sleep, a weak reaction of the pupils, a light touch to the cornea of the patient's eye is accompanied by a reaction, the swallowing reflex is preserved;
• Coma - deep sleep, there are no reactions.

An epileptiform (similar to epilepsy) seizure is also one of the possible debuts of a hemorrhagic stroke. Typically, this symptom occurs in 10% of patients with lobar stroke.

In case of impairment of consciousness, it is necessary to prevent the tongue from sinking, to prevent the blocking of the airways. Before the arrival of an ambulance, the victim should be laid down in a horizontal position, his head slightly raised.

Up to 90% of patients with GI have a disorder of consciousness upon admission to the clinic. In some patients, the regression of consciousness is gradual, from stunning and lower, up to coma. At the first sign of a stroke, you must immediately call an ambulance. It is very important!

The probability of death in hemorrhagic stroke, depending on the patient's condition:

• Clear consciousness - up to 20%
• Stun - up to 30%;
• Somnolence (slight clouding of consciousness) - up to 56%;
• Sopor (subcomme - deep depression of consciousness) - up to 85%
• Coma - up to 90%.

Causes of hemorrhagic stroke

In about 2-15% of cases, the causes of hemorrhagic stroke remain unrecognized. In the history of 25% of patients, there are references to acute disorders of cerebral circulation of unknown etiology.

The main proven causes of hemorrhagic stroke:

• Arterial hypertension;
• Smoking;
• Diabetes;
• Dyslipidemia;
• Atrial fibrillation;
• Diseases of the cardiovascular system;
• Asymptomatic stenosis of the carotid arteries;
• Sickle cell anemia;
• Obesity;
• Sedentary lifestyle.

GI reasons that a person can correct on their own

Simple regular prevention of strokes, based on knowledge of the pathophysiology of the cardiovascular system, reduces the risk of strokes and premature death of people looking after their health by 10-30%.

Arterial hypertension

High blood pressure is recorded in 70-80% of stroke survivors

Prolonged hypertension is accompanied by atherosclerosis, loss of elasticity, forced vasodilation, and thinning of their walls. A sharp jump in blood pressure can provoke a rupture of the walls of the vessels of the brain.

Recommended blood pressure (BP):

• Men / women under 40:

  • optimal - 120/80 mm Hg;
  • normal - 130/85 mm Hg

• Men:

  • from 40 to 49 years old - 150/98 mm Hg
  • from 49 to 79 years old - 155/103 mm Hg

• Women:

  • from 40 to 49 years old 150/94 mm Hg
  • from 49 to 79 years old 177/97 mm Hg

Medication correction of blood pressure is an important factor in the prevention of stroke. Decrease in pressure by 5 mm Hg. reduces the risk of stroke by 14%, the risk of death by 7%.

Correction must be started at pressure:

• above 140/90 in a population of people with no history of cardiovascular disease;
• above 130/85 in the population of people suffering from ischemic heart disease, diabetes, kidney disease, cerebrovascular pathologies.

For self-monitoring of blood pressure, automatic and semi-automatic tonometers with a shoulder or wrist cuff are recommended (Omron, Nissei, AND, others). The choice of drugs must be agreed with a cardiologist. Referrals to a cardiologist `` on a quota '' basis can be obtained from a general practitioner at the local polyclinic. The examination can also be done for a fee at the cardiology center.

Dyslipidemia

Violation of lipid metabolism with an excess of low-density cholesterol leads to a narrowing of the lumen of the cerebral vessels, deterioration of the nutrition of the nervous tissue, a decrease in brain function and the development of atherosclerosis.

Atherosclerosis, including at the subclinical stage, is the cause of the onset of hemorrhagic stroke. Normal level:

• total cholesterol - up to 5.0 mmol / l;
• low density lipoproteins (LDL) - 2.6-3.3 mmol / l;
• high density lipoprotein (HDL) - 1.03-1.52 mmol / l.

With an elevated LDL level, the choice of drugs must be agreed with the therapist. Correction of cholesterol levels is carried out by pharmacological agents - statins, fibrates, niacin. Statins are very effective in ischemic strokes, less effective in cerebral hemorrhages.

Diabetes

Fasting plasma glucose values:

• less than 6.1 mmol / l - normal level;
• from 6.1 to 7.0 mmol / l - a harbinger of disorders of carbohydrate metabolism;
• more than 7.0 mmol / l - diabetes mellitus (clinical confirmation is required).

All detailed information about diabetes mellitus (here)

Whole blood glucose readings differ. Portable blood glucose self-monitoring machines are available commercially. The machines have a built-in high / low glucose notification function. In Russia, portable blood glucose meters of the OneTouch series, Omelon and others are recommended for use. The therapeutic adjustment of carbohydrate metabolism is agreed with the doctor; the choice of pharmaceuticals depends on the type of diabetes.

Pregnancy and postpartum conditions

Hemorrhagic stroke in the postpartum period is diagnosed in 30% of all strokes in women 30-40 years old

Subcortical hemorrhages are more common, less often - hemorrhages in the parenchyma. Hemorrhages are usually caused by massive birth blood loss and associated disorders in the cardiovascular system. Treatment is carried out taking into account the nature of the identified pathology.

Smoking

Smoking is one of the main causes of stroke. The stimulating effect of nicotine on the pathogenesis of atherosclerosis has been proven. Quitting smoking significantly reduces the risk of stroke. (see SCORE cardiovascular risk assessment table)

Sedentary lifestyle

The call to go in for sports applies more to young people. For older and elderly people, it is enough to perform moderate physical exercises as part of a group of the same age, or regularly walk in the fresh air.

Acute period of hemorrhagic stroke

When a patient is admitted to the clinic before urgent therapeutic measures, neuroimaging of the brain and a clinical assessment of the patient's condition are performed.

Symptoms of the acute period of GI that are important for determining the prognosis of the disease

The following symptoms are considered unfavorable (except for disorders of consciousness):

• The volume of hematoma in the brain substance is more than 7 cm ³;
• The volume of intraventricular hemorrhage is more than 2 cm ³;
• The patient's age group is 60 years and older;
• Arterial hypertension;
• Concomitant chronic pathology;
• Dislocation syndromes.

Dislocation syndromes are clinical manifestations of acute cerebral disorders that develop as a result of pathological expansion of the volume of the brain when its normal location (location) in the skull changes.

There are nine variants of the displacement of the medulla in the cranium relative to the usual location, including two main ones, which are of vital importance in stroke.

The displacement of the brain towards anatomical structures is characterized by the following symptoms:

• Temporo-tentorial, cerebellar-tentorial wedging - accompanied by nystagmus (rhythmic movements of the eyeballs), paresis of the gaze (the gaze is not able to follow the movement of the object), decreased response to light, muscle atony, arrhythmia on the ECG;
• Cerebellar tonsils into the foramen magnum - accompanied by pathological types of arrhythmic breathing, disappearance of the pharyngeal reflex, decreased muscle tone and blood pressure.

Other symptoms of an unfavorable prognosis of intracranial hemorrhage

The study should be carried out only by a trained doctor, as incompetent manipulations can aggravate the patient's serious condition.

The symptoms are as follows:

• Anisocoria - different pupil diameters;
• Decreased pupil response to light;
• Positive oculocephalic reflex - in a person in a coma, when the head is forcibly turned, the pupils are displaced in the direction opposite to the tilt;
• Bulbar syndrome - impaired speech, sound pronunciation and swallowing, lethargy of the muscles of the tongue and lips;
• Pseudobulbar syndrome - the same signs as in bulbar syndrome, but there is no lethargy of the muscles of the tongue and lips, however, there is an unreasonable crying and laughter of the patient.

The patient's condition is investigated in the dynamics of pathogenesis. Hemorrhagic strokes are characterized by two peaks of exacerbation of the disease, which coincide with the maximum mortality of patients:

• On the second or fourth day - the peak is associated with the onset of pathogenesis in the focus of hemorrhagic stroke;
• On the tenth-twelfth day - the peak is due to the addition of complications of pathogenesis.

Coma with hemorrhagic stroke

Approximately 90% of HI patients in a stupor or coma state die in the first five days, despite intensive therapy

Disorders of consciousness are characteristic of many pathologies, manifested by inhibition of the functions of the reticular formation of the brain.

Brain dysfunctions develop under the influence of:

• Endo- and exotoxins - derivatives of end products of metabolism;
• Oxygen and energy starvation of the brain;
• Metabolic disorders in the structures of the brain;
• Expansion of the volume of the brain substance.

Of greatest importance in the development of coma are acidosis, cerebral edema, increased intracranial pressure, impaired microcirculation of brain and blood fluids.

Coma affects the functioning of the respiratory system, excretions (kidneys), digestion (liver, intestines).

Removal from a coma at home is impossible, and very difficult even in intensive care.

The clinical definition of coma is carried out according to the GCS (Glasgow Coma Scale), some other techniques are used that are important for clinicians. There are four stages of coma. The lightest is the first, and the hopeless state of the patient corresponds to the fourth stage of coma.

Passing a medical and social examination

A patient who has suffered a stroke is defined as a temporarily disabled person (TD). With an unfavorable labor prognosis, after 3 months from the start of treatment, the question arises of sending a person to a medical and social examination (MSE) for examination for:

• Disability (there are no prospects for the restoration of functions);
• Continuation of treatment on sick leave (there is a possibility of positive dynamics and restoration of functions).

The ITU Bureau makes a decision based on the data of an objective examination of the patient, the results of instrumental and laboratory studies.

What should be considered before a disability examination?

Which doctors do you need to go through?

Clinical reports required by the ITU Bureau:

• Cardiologist;
• Endocrinologist;
• Oculist;
• Neurologist / therapist.

List of laboratory and instrumental studies required by the ITU Bureau:

• General and biochemical blood parameters;
• ECG, rheoencephalography (REG), electroencephalogram (EEG);
• Computed tomography (CT), magnetic resonance imaging (MRI);
• X-ray in different projections of the skull and cervical vertebrae, including with contrast;
• Doppler ultrasound of the vessels of the neck and brain (USDG) / transcranial Doppler (TCD);
• Lumbar puncture (if indicated).

The specialists of the ITU bureau conduct an examination of the patient's ability to work according to several indicators, including taking into account:

• The severity of pyramidal disorders (the ability to move, the ability to overcome obstacles, coordination of body position in space, the severity of paresis;
• The severity of extrapyramidal disorders (problems with speech, slowness in performing habitual actions, chorea, athetosis, choreoathetosis, hemiballism, myoclonus, facial hemispasm);
• The state of the functions of the organs of vision (hemianopsia, narrowing of the field of vision, amaurosis, amblyopia, visual agnosia, decreased detailed vision);
• The state of cerebral functions (aphasia, motor deficit, difficulty in communication);
• Epileptic seizures (focal / partial, generalized);
• Disorders of mental functions (asthenia, dementia, decreased intellectual status, cognitive defects).

Factors considered by the ITU Commission before making a decision:

• Unfavorable course of the disease, the possibility of recurrent stroke;
• Unclear work prognosis, persistence of cerebral disorders, slow recovery of functions;
• Inability to return to work, decrease in intellectual and physical capabilities below the level required to continue working on the same conditions.

Disability groups for hemorrhagic stroke:

Group III involves a return to work, while taking into account the need to create easier working conditions;

Group II assumes the presence of restrictions on the ability to move, orientation and self-service;

Group I assumes pronounced disorders, loss of self-service ability and ability to move, and a decrease in intelligence.

Rankin Stroke Outcome Scale and Barthel Index (here)

Hemorrhagic stroke treatment

There is a generally accepted algorithm for choosing a method for treating hemorrhagic stroke.

Surgery

Surgical tactics are indicated for:

• Lobar and lateral hemorrhages of medium and large volume;
• Deterioration of the patient's condition in a dynamic CT / MRI study;
• Hematomas of the cerebellum and brain stem, causing neurological symptoms.

Contraindications for surgical tactics:

• Deep coma with stem dysfunctions (100% mortality);
• Medial hematomas of any size (mortality 90-100%).

Conservative therapy is indicated for:

• Stable condition of the patient and the absence of neurological deficits;
• Small supratentorial hematomas.

There are two main approaches to performing the operation, namely:

• Classic microneurosurgical interventions;
• Endoscopic techniques of microneurosurgery.

Visual verification of hematomas before surgery includes CT, MRI studies, cerebral angiography and other studies if indicated.

Surgical intervention is prescribed according to the results of neuroimaging:

• The volume of the VMG is more than 30 ml;
• Dislocation of cerebral cisterns;
• Deterioration of the clinical and neurological status.

Taking into account the qualification training of the surgical team, the best results are shown by the endoscopic technique (gentle, it makes it possible to visualize the cavity of the operation). The classical method of microsurgical intervention is good for the difficulties in controlling the homeostasis of the brain tissue.

Conservative therapy and prevention

Here we list the drugs of different pharmacological groups used for the treatment of the acute period of hemorrhagic stroke. Regulation of blood pressure and angiospasm is necessary in the acute period of hemorrhagic stroke.

Antihypertensive drugs:

• Selective beta-blockers (Atenolol, Metoprolol, Betaxolol, Bisoprolol, Nebivolol, Esmolol, Acebutolol);
• Non-selective beta-blockers (Anaprilin, Nadolol, Sotalol, Timolol, Oxprenolol, Pindolol, Penbutolol);
• Mixed beta-blockers (Carvedilol, Labetalol).

Calcium antagonists:

• First generation (Isoptin, Finoptin, Fenigidin, Adalat, Corinfar, Kordafen, Cordipin, Diazem, Diltiazem);
• Second generation (Gallopamil, Anipamil, Falipamil, Isradipine / Lomir, Amlodipine / Norvasc, Felodipine / Plendil, Nitrendipine / Octidipine, Nimodipine / Nimotop, Nicardipine, Lacidipine / Lazipil, Riodipin);
• Third generation (Klentiazem).

Antispasmodics:

• Direct action (Papaverin, No-shpa, Drotaverin, Nitroglycerin, Otilonia bromide, Mebeverin, Galidor, Gimekromon);
• Indirect action (Aprofen, Ganglefen, Atropine, Difacil, Buscopan).

ACE (angiotensin converting enzyme) inhibitors:

• Sulfhydryl group (Benazepril, Captopril, Zofenopril);
• Carboxyl group (Cilazapril, Enalapril, Lisinopril, Perindopril, Quinapril, Ramipril, Spirapril, Trandolapril);
• Phosphinyl group (Fosinopril).

The following auxiliary medicines are used to treat hemorrhagic stroke:

• Sedatives (Diazepam, Elenium, Phenobarbital);
• Hemostatic (Dicinon / Etamsylate, Rutin, Vikasol, Ascorbic acid);
• Antiprotease (Gordox, Contrikal);
• Multivitamins with micro and macro elements (Calcium pantothenate, Calcium gluconate);
• Antifibrinolytic (Gamma-aminocaproic acid, Rheopolyglucin);
• Nootropic (Cortexin);
• Laxatives (Regulax, Glaxena).

Drugs for the regulation of intracranial pressure and cerebral edema:

• Diuretics (Mannitol, Lasix);
• Corticosteroids (dexamethasonzone);
• Plasma-substituting (Reogluman).

Thus, hemorrhagic stroke is a severe form of acute disorders of cerebral circulation, which is characterized by a high level of mortality and disability. The recovery period can last up to two years. Rehabilitation is aimed at teaching the patient how to overcome neurological deficits. Disability is accompanied by a significant decrease in the quality of life of the patient and his environment.

Author of the article: Sokov Andrey Vladimirovich | Neurologist

Education: In 2005 completed an internship at the IM Sechenov First Moscow State Medical University and received a diploma in Neurology. In 2009, completed postgraduate studies in the specialty "Nervous diseases".