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gemorragicheskij insult

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

Timely detection of early signs of disease and rapid delivery of the patient to the clinic by about 15% increases the probability of a favorable outcome of hemorrhagic stroke.


What is hemorrhagic stroke?

Nosological form includes two terms: "hemorrhage"is bleeding, and the word"stroke" means the infarction (ischemic necrosis) of a portion of the brain.

Hemorrhagic stroke is a hypertensive hemorrhage in the parenchyma of the brain, accompanied by acute violation of cerebral circulation with loss of function of the affected area, development of pathogenesis in the core and perifocal (around the nucleus) area. The disease manifested General and local neurological symptoms.

Hemorrhagic stroke is mainly a complication of hypertension.

More severe pathogenesis in comparison with ischemic stroke is associated with a cumulative effect from:

  • Bleeding in brain tissue, compression of the surrounding vessels;
  • Inflammatory-necrotic processes in the nucleus of the stroke;
  • Dystrophic and inflammatory processes in the periphery of the nucleus.

There are two main types of bleeding into the brain, with different origins:

  • Hemorrhagic stroke (GI) haemorrhage/infiltration of the brain parenchyma;
  • Subarachnoid hemorrhage (SAH) – bleeding in the cerebral cortex of non-traumatic character, not related to the malformation of blood vessels.

During the initial observation of the patient is diagnosed as hemorrhage intracerebral hematoma (ICH). Differentiation is conducted in the clinic based on the results of instrumental (MRI, CT) imaging of brain structures and the skull.

There are several variants of localization of the hemorrhage in the brain, namely:

  • Putaminal lateral (side) – the side of the internal capsule;
  • Subcortical (sub-cortical);
  • Lobar, the first lobe;
  • Thalamic (medial) – located to the center of the inner capsule;
  • Mixed;
  • Cerebellar;
  • Stem (bridge).

Widespreadputaminal strokes – they make up half of all types of hemorrhagic strokes, rarely, subcortical and thalamic – about 15% for each type. Much less likely to detect bleeding in the cerebellum and the brain stem is up to 8% of all strokes.

The most severe destruction of the body is massive hemorrhage in hemisphere, the stem or the cerebellum of the brain. Hemorrhagic strokes often develop in men who are prone to hypertension and having harmful habits. The likelihood of bleeding into the brain increases with age.

In women aged 30-40 years, the risk of hemorrhagic stroke associated with childbirth and the puerperium and is caused by layering of the tribal massive/PPH violations in the cardiovascular system.

Contents:


Symptoms of hemorrhagic stroke

We know more than hundreds of different clinical symptoms of hemorrhagic stroke, it is also possible transformation of ischemic stroke to hemorrhagic. This greatly complicates the differential diagnosis. The primary symptoms indicating a stroke, you must define the description of the feelings of the patient, changes in speech, severe headaches, disturbance of consciousness.

Use simple tests to determine the strokes (here)

Possible precursors of hemorrhagic stroke

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

    • They appear shortly before the attack, however, are not necessarily a sign of GI.

    For hemorrhagic stroke is more typical of the sudden onset of the disease. The day before or directly before the attack of possible stress in the form of physical and/or emotional stress.

    Attention! Any of the following signs and other symptoms indicating a sudden breakdown of vital functions – a reason for emergencyambulance (algorithm treatment in the ambulance here).

    During a telephone conversation with the operator must clearly describe the patient discovered the signs of a stroke.

    Symptoms of hemorrhagic stroke in human being in mind:

    Symptoms of hemorrhagic stroke in an unconscious person:

    Do not attempt to return the patient to consciousness!

    Share four distinct stages of regression of consciousness. Independently they can be defined as:

    • The stunned uncomprehending look sick, weak responsiveness to others;
    • Somnolence – like sleep with open eyes, gaze fixed in space;
    • Stupor – like deep sleep, poor pupillary response, light touch to the cornea of the patient is accompanied by a response, saved the swallowing reflex;
    • Coma – a deep sleep without any reaction.

    Epileptiform (resembling epilepsy) a seizure – as one of the possible debuts of hemorrhagic stroke. Usually this symptom occurs in 10% of patients with stroke lobar localization.

    When disturbance of consciousness and the need to avoid the tongue, to prevent overlap of the respiratory tract. The victim until the arrival of the ambulance should be placed in a horizontal position, the head slightly raised.

    Up to 90% of patients with GI admission to the hospital have delirium.

    In some patients regression of consciousness is gradual, from stun and lower, until Tuesday. At the first signs of a stroke should immediately call an ambulance. This is very important!

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

    • Clear consciousness – 20%
    • Stun – 30%;
    • Somnolence (light dizziness) to 56%;
    • Stupor (subgame – deep depression of consciousness) – up to 85%
    • Coma – up to 90%.

    Causes of hemorrhagic stroke

    Approximately 2-15% of cases of hemorrhagic causes of stroke remain unidentified. History 25% of patients there is mention of acute disorders of cerebral circulation are unclear etiology.

    The major proven causes of hemorrhagic stroke:

    Causes GI, which one can adjust by yourself

    Simple regular prevention of stroke based on knowledge of the pathophysiology of the cardiovascular system, 10-30% reduced risk of stroke and premature death of people caring about their health.

    Hypertension

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

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

    The recommended blood pressure (BP):

    • Men/women up to 40 years:

      • optimal – 120/80 mm of mercury.St.;
      • normal – 130/85 mm Hg.St.

    • Men:

      • from 40 to 49 years – 150/98 mm Hg.St.
      • from 49 to 79 years, 155/103 mm of mercury.St.

    • Women:

      • from 40 to 49 years 150/94 mm Hg.St.
      • from 49 to 79 years 177/97 mm of mercury.St.

    Pharmacological treatment of AD is an important factor in stroke prevention. A pressure reduction of 5 mm of mercury.St. reduces the risk of stroke by 14%, the risk of death by 7%.

    Correction should start when the pressure:

    • above 140/90 in the population of people with no previous history of cardiovascular disease;

    • above 130/85 in the population of people suffering from coronary heart disease, diabetes, kidney diseases, cerebrovascular pathologies.

    For self-monitoring of blood pressure recommended blood pressure monitors automatic andsemi-automatic, shoulder or wrist cuff (Omron, Nissei, AND other). The choice of medications should be coordinated with the cardiologist. Referral to cardiologist "quota" can be obtained at the local clinic by a physician. The examination can also be held in charge of the cardiology center.

    Dyslipidemia

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

    Atherosclerosis, including in the subclinical stage – the reason for the debut of a hemorrhagic stroke. Normal level:

    • total cholesterol – 5.0 mmol/l;
    • low density lipoprotein (LDL) of 2.6-3.3 mmol/l;
    • high density lipoproteins (HDL) – 1,03-of 1.52 mmol/L.

    With the increased level of LDL, the selection of drugs should be agreed with the therapist. Correction of cholesterol is pharmacological agents – statins, fibrates, Niacin. Statins are highly effective in ischemic stroke, is less effective for cerebral hemorrhages.

    Diabetes

    The indicators of glucose in plasma blood on an empty stomach:

    • less than 6.1 mmol/l – normal level;
    • from 6.1 to 7.0 mmol/l – a harbinger of metabolic disorders;
    • more than 7.0 mmol/l – diabetes (requires clinical confirmation).

    Detailed information about diabetes (here)

    Indicators of the level of glucose in whole blood differ. In commercially available portable devices for self-monitoring of glucose levels in the blood. The devices have a built-in feature notification of high/low glucose levels. In Russia is recommended for use with portable glucometers OneTouch series, Omelon and others. Therapeutic correction of carbohydrate metabolism agree with the doctor, the choice of medicines depends on the type of diabetes.

    Pregnancy and the postpartum state

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

    More often subcortical hemorrhage, rarely – bleeding in the parenchyma. Hemorrhage is usually caused by massive blood loss and genericrelated disorders in the cardiovascular system. The treatment is carried out taking into account the nature of identified pathology.

    Smoking

    Smoking is one of the main causes of stroke. Proven to push the influence of nicotine in the pathogenesis of atherosclerosis. Quitting Smoking greatly reduces the risk of stroke. (see table determining the risk of developing cardiovascular disease SCORE)

    A sedentary lifestyle

    The call to exercise is more closely related to young people. For senior and elderly enough to perform moderate exercise in the composition of coeval groups of people, or regularly walk in the fresh air.

    The acute period of hemorrhagic stroke

    When a patient in the clinic until the urgent therapeutic measures conducted brain imaging of the brain and clinical evaluation of the patient.

    Symptoms of acute GI of importance to determine the prognosis of the disease

    Adverse (except for disorders of consciousness) are the following symptoms:

    • Hematoma in the substance of the brain more than 7 cm3;

    • The volume of intraventricular hemorrhage greater than 2 cm3;

    • Patient age group from 60 years and older;
    • Arterial hypertension;
    • And related chronic pathology;
    • Dislocation syndromes.

    Dislocation syndrome is the clinical manifestations of acute brain disorders that develop as a result of the abnormal enlargement of the volume of the brain to change its normal location (location) in the skull.

    There are nine variants of the displacement of brain matter in the skull relative to the usual locations, including two main, having a vital importance in stroke.

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

    • Temporal-tentorial, cerebellar-tentorial herniation is accompanied by nystagmus (rhythmic movement of the eyeballs), paralysis of gaze (the gaze is not able to follow the movement of the object), reduced reaction to light, muscle atony, cardiac dysrhythmia on ECG;

    • Of the cerebellar tonsils in the foramen Magnum is accompanied by pathological types, irregular breathing and loss of gag reflex, reduced muscle tone and blood pressure.

    Other symptoms of unfavorable prognosis for intracranial hemorrhage

    The study should only be performed by a trained physician, as incompetent manipulation can aggravate the serious condition of the patient.

    The symptoms are the following:

    • Anisocoria different diameter of pupils;
    • The reduction reaction of pupils to light;
    • Positive oculocephalic reflex – man in a coma at the violent turn of the head, the pupils shifted in the opposite tilt direction;
    • Bulbar syndrome – a violation of speech, sound articulation and swallowing, weakness of the muscles of the tongue and lips;
    • Pseudobulbar syndrome – the same characteristics that in bulbar syndrome, but there is no weakness of the muscles of the tongue and lips, however, there is a causeless crying and laughing patient.

    The condition of the patient is investigated in the dynamics of pathogenesis. For hemorrhagic strokes characterized by two peaks of acute diseases, which coincide with the maximum lethality of patients:

    • On the second day of the fourth peak is associated with the early pathogenesis in the outbreak of hemorrhagic stroke;
    • On the tenth-twelfth day – the peak is due to the complications of the pathogenesis.

    Coma in hemorrhagic stroke

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

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

    Violations functions of the brain develop under the influence:

    • Endo - and exotoxins – derived end products of metabolism;
    • Oxygen and energy starvation of the brain;
    • Of metabolic disorders in the brain;
    • The expansion of the substance of the brain.

    The greatest value in the development of coma have acidosis, swelling of the brain, increased intracranial pressure, disturbance of microcirculation of brain fluids and blood.

    The coma affects the functioning of the organs of respiration, discharge (kidneys) digestive system (liver, intestine).

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

    The clinical definition of a coma is carried out according to the GCS (Glasgow coma scale), use some other techniques relevant to clinicians. Preko and distinguish four stages of coma. The easiest first, and the hopeless condition of the patientthe fourth stage of coma.


    The passage of mediko-social examination

    The patient, a stroke is defined as a person temporarily incapacitated (CWF). In adverse employment forecast in 3 months from start of treatment raises the question of the direction of a person for medico-social examination (MSE) to examination on the subject:

    • Disability (no prospects for recovery functions);
    • Continued treatment of the sick (there is a probability of a positive dynamics and restoration of function).

    Bureau of the ITU decides, based on the data of objective research of the patient, results of laboratory and instrumental studies.

    What to consider before you expertise on disability?

    What doctors you have to go through?

    Required Bureau ITU clinical opinion:

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

    A list of laboratory and instrumental studies, required the Bureau of the ITU:

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

    The experts of the Bureau, ITU carried out an examination of disability of the patient on several indicators, including take into account:

    • The severity of pyramidal disorders (mobility, ability to overcome obstacles, coordination of body position in space, the severity of paresis;
    • The severity of extrapyramidal disorders (speech problems, slowness of execution of habitual action, chorea, atetoz, horeoatetoz, hemiballism, myoclonia, a hemifacial spasm);
    • The state of functions of organs of vision (hemianopsia, narrowing of the visual field, amaurosis, amblyopia, visual agnosia, reduced detailed view);
    • The brain functions (aphasia, motor deficit, difficulty in communication);
    • Seizures epileptic seizures (focal/partial,generalized);
    • Impaired mental function (fatigue, cognitive impairment, decreased mental status, cognitive defects).

    Factors considered by the ITU before making a decision:

    • An unfavorable course of the disease, the possibility of recurrence of stroke;
    • Uncertain labor forecast, the preservation of brain damage, slow recovery functions;
    • The inability to return to work, decreased mental and physical capacity below the level required for continued employment on the same terms.

    Of disability in hemorrhagic stroke:

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

    II group implies the existence of restrictions on ability to move, orientation, and self-service capabilities;

    I group suggests pronounced violations, the loss of the ability of self-service and unable to walk, intellectual impairment.

    Outcome scale stroke, Rankin and Barthel index (here)


    Treatment of hemorrhagic stroke

    There is a common algorithm for selecting the method of treatment of hemorrhagic stroke.

    Surgical treatment

    Surgical approach is indicated for:

    • Lobar and lateral hemorrhages medium and large volume;
    • The deterioration of the patient dynamic study CT/MRI;
    • Hematomas of the cerebellum and the brain stem, causing neurological symptoms.

    Contraindications of surgical tactics:

    • Deep coma with stem dysfunction (100% mortality);
    • Medial hematoma of any size (the mortality rate of 90-100%).

    Conservative therapy is indicated for:

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

    There are two basic approaches to the operation, namely:

    • Classic microneurosurgical intervention;
    • Endoscopic techniques of microneurosurgery.

    Visual verification of the hematoma before surgery includes CT, MRI studies, angiography of cerebral vessels, and other studiesindications.

    Surgical intervention is prescribed according to the results of neuroimaging:

    • The ICH volume more than 30 ml;
    • Dislocation of brain tanks;
    • Deterioration of clinical and neurological status.

    Taking into account the qualification of surgical teams, the best results shows endoscopic technique (gentle, enables visualization surgery). The classic method of microsurgical intervention is good for difficulties in the control of homeostasis of brain tissue.

    Conservative therapy

    Here, we give drugs of different pharmacological groups used for therapy of the acute period of hemorrhagic stroke. Regulation of blood pressure and vasospasm are necessary in the acute period of hemorrhagic stroke.

    Antihypertensive drugs:

    • Selective beta-blockers (Atenolol, Metoprolol, Betaxolol, Bisoprolol, Nebivolol, Esmolol, Acebutolol);
    • Nonselective beta-blockers (Inderal, Nadolol, Sotalol, Timolol, Oksprenolol, Pindolol, Penbutolol);
    • Mixed beta-blockers (Carvedilol, Labetalol).

    Calcium antagonists:

    • The first generation (Isoptin, Phenoptin, Fenigidin, adalat, Corinfar, Kordafen, Cordipin, Diazem, Diltiazem);
    • Second generation (Gallopamil, Anipamil, FilePanel, Isradipine/Lomir, Amlodipine/norvasc, Felodipine/Plendil, Nitrendipin/Activpen, Nimodipine/Nimotop, Nicardipine, Lacidipine/Lacipil, Redipen/Foridon);
    • Third generation (Clentiazem).

    Antispasmodics:

    • Direct action (Papaverine, no-Spa, Drotaverine, Nitroglycerin, otiloniya bromide, Mebeverine, halidorum, Gimekromon);
    • Indirect action (Aprofen, Anglefan, Atropine, Dificil, Buscopan).

    ACE inhibitors (angiotensin converting enzyme):

    • Sulfhydryl groups (Benazepril, Captopril, Zofenopril);
    • Carboxyl group (Cilazapril, enalapril, lisinopril, Perindopril, Quinapril, Ramipril, Spirapril, Trandolapril);
    • Gostinichnoe group (Fosinopril).

    For the treatment of hemorrhagic stroke uses the following auxiliary medicines:

    • Sedatives (Diazepam, Valium, Phenobarbital);
    • Styptic (Dicynone/Etamzilat, Rutin, Menadione, Ascorbic acid);
    • Antiproteaznaya(Gordox, Contrical);
    • Multivitamins with micro and macronutrients (Calcium Pantothenate, calcium Gluconate);
    • Antifibrinolytic (Gamma-aminocaproic acid, Reopoligljukin);
    • Nootropic (Cortexin);
    • Laxatives (But, Glaksena).

    Medication to control intracranial pressure and cerebral edema:

    • Diuretics (Mannitol, Lasix);
    • Corticosteroids (Dexamethasone);
    • Plasma Expanders (Reoglumann).

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