hemorrhagic cerebral infarction
Introduction
Introduction to hemorrhagic cerebral ischemia Hemorrhagicinfarction (HI) refers to secondary hemorrhage in the infarct area caused by revascularization of blood vessels in the ischemic area during cerebral infarction. Brain CT scan or brain MRI examination shows low originality. There is scattered or localized high-density shadow in the density zone. This phenomenon is called hemorrhagic cerebral infarction or cerebral hemorrhage after cerebral infarction. The pathogenesis of hemorrhagic cerebral infarction is very complicated. The basic conditions for its occurrence are nothing more than the damage of the blood vessel wall after ischemia, the increase and decrease of the degree of edema of softened and necrotic brain tissue, the change of hemodynamics, the blood flow of the lesion area. Recanalization, reperfusion pressure or collateral circulation of the infarct edge, secondary fibrinolysis and coagulopathy, and the most critical mechanism is reperfusion of blood flow. basic knowledge The proportion of illness: 0.03% Susceptible people: no specific people Mode of infection: non-infectious Complications: upper gastrointestinal bleeding acne depression anxiety
Cause
Cause of hemorrhagic cerebral infarction
Cardiac cerebral embolism (30%):
Cardiac cerebral embolism is the most common, accounting for more than half, cardiac embolism such as atrial fibrillation, rheumatic heart disease, valvular disease, sick sinus syndrome, bacterial endocarditis, mitral valve prolapse, apex Annular calcification, atrial myxoma, left ventricular wall thrombus such as left ventricular aneurysm after myocardial infarction, congestive cardiomyopathy and congestive heart failure.
Large area of cerebral infarction (25%):
The formation of hemorrhagic cerebral infarction is closely related to the infarct size. The occurrence of hemorrhagic cerebral infarction is positively correlated with the infarct size. The greater the infarct size, the higher the incidence of hemorrhagic cerebral infarction, and the infarct size is greater than that of the ipsilateral cerebral hemisphere. Hemorrhagic cerebral infarction is almost inevitable in large infarcts.
Other (15%):
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In conclusion, the occurrence of hemorrhagic cerebral infarction is mainly related to cerebral embolism caused by heart disease, and is related to the size of infarct size, and the time after infarction and the use of thrombolysis, anticoagulation, and vasodilator.
Pathogenesis
Cerebral embolism, large area cerebral infarction, cerebral infarction with hypertension, elevated blood pressure after cerebral infarction, elevated blood glucose, elevated white blood cells, high fever, etc., easy to induce hemorrhagic cerebral infarction, the pathogenesis may be the following Several factors are related.
1. Embolism migration and recanalization Because hemorrhagic cerebral infarction is mostly caused by cerebral embolism, the cause of bleeding is mainly the "embolic migration" theory. The intravascular embolus breaks and migrates to the distal end. The blood vessels have developed ischemia and necrosis, and rupture and hemorrhage under the action of blood pressure to form hemorrhagic cerebral infarction. When the embolus causes vascular occlusion, the embolus is disintegrated due to the influence of normal fibrinolysis mechanism, and cerebral ischemia The resulting compensatory vasodilation causes the embolus to advance toward the distal end of the occluded vessel, thus causing leakage of the capillary endothelium due to ischemic injury in the original ischemic area, which is affected by the intensive arterial perfusion pressure after reperfusion. Secondary bleeding in the infarct zone can be extensive, and Fisher believes that almost all embolic lesions at autopsy can have small focal hemorrhage.
2. Large-scale cerebral infarction clinical brain CT scan, brain MRI examination showed that large area cerebral infarction and large-scale edema after infarction are risk factors for hemorrhagic cerebral infarction. Large area cerebral infarction occurs in the first half of the skull base Willis ring, embolism The area is calculated according to the Pullicino method, and 15 ml or more is a large area embolization.
Large area cerebral infarction is often accompanied by obvious cerebral edema, so that the surrounding blood vessels are compressed, blood stasis, edema subsides, edema compression and revascularization of blood vessels, due to long-term ischemia and hypoxia, cerebral vascular permeability is enhanced, prone to osmosis Blood and bleeding.
3. The collateral circulation formed early animal experiments found that good collateral circulation is a necessary condition for hemorrhagic cerebral infarction. The possible mechanism of hemorrhagic cerebral infarction caused by collateral circulation is considered to be cerebral infarction, especially after large infarction. As cerebral edema causes ischemia, necrosis and endothelial damage in the capillaries surrounding the cerebral infarction, the edema subsides the collateral circulation in the second week of the disease, and the rupture of the capillaries that have occurred necrosis causes peripheral spots or flaky hemorrhage. In addition, a few days to a few weeks after cerebral infarction, capillary proliferation is active, easy to communicate with the collateral circulation of the pia mater, and blood oozing out of the immature cortical blood vessels.
4. Anticoagulant thrombolytic therapy for anticoagulant thrombolytic therapy has been controversial in the past. Some people think that hemorrhagic cerebral infarction is usually the natural development of embolic stroke, and it has nothing to do with anticoagulant therapy. It is suggested that the chemical environment of infarcted brain tissue itself may be It has a great influence on the occurrence and extent of secondary bleeding.
5. Hyperglycemia Some people think that the occurrence of hemorrhagic cerebral infarction is related to the rupture of capillary endothelium in diabetic patients.
6. The onset time of hemorrhagic cerebral infarction is related to a variety of factors, but the sooner or later onset time directly affects the course of disease and clinical prognosis. Early onset is often associated with embolism migration, clinical symptoms suddenly increase, and delayed type is mostly related to collateral circulation. .
In short, the pathogenesis of hemorrhagic cerebral infarction is very complicated, and the basic conditions for its occurrence are nothing more than the damage of the blood vessel wall after ischemia, the increase and decrease of the degree of edema of softened and necrotic brain tissue, the change of hemodynamics, the blood of the lesion area. Flow recanalization, increased reperfusion pressure or open collateral circulation at the infarct border, secondary fibrinolysis and coagulopathy, and the most critical mechanism is reperfusion of blood flow.
Prevention
Hemorrhagic cerebral infarction
Because the main causes of hemorrhagic cerebral infarction are heart disease, hypertension, atherosclerosis, hyperlipidemia, diabetes, etc., it is necessary to strengthen the etiology of the above diseases or may cause hemorrhagic infarction, such as actively controlling heart disease, Reasonable adjustment of blood pressure, etc., the specific method is:
1. For patients with hypertension, the blood pressure should be controlled at a reasonable level. Because the blood pressure is too high, it is easy to cause microvascular angiomas and atherosclerotic arteries in the brain to rupture and hemorrhage. Lower blood pressure is too low or too fast, which may lead to cerebral insufficiency. Even cerebral infarction or watershed infarction may occur, so it should prevent various factors such as sudden decrease in blood pressure, slow cerebral blood flow, increased blood viscosity, and increased blood coagulation.
2. For the acute phase of cerebral infarction, thrombolytic anticoagulation and other treatments should be applied on the basis of certain laboratory control to minimize the occurrence of hemorrhagic cerebral infarction.
3. Pay attention to mental and mental health Many episodes of cerebral infarction are related to emotional excitement.
4. Pay attention to changing bad habits. Moderate physical activities are good for health. Avoid bad habits such as smoking, alcoholism, overeating, and overeating. It should be based on low-fat, low-calorie, low-salt diets, and have enough high-quality protein and vitamins. Cellulose and trace elements, foods that are not conducive to health, mildew, salted fish, cold food, do not meet the requirements of food hygiene, fasting, to prevent hyperlipidemia, promote atherosclerosis.
5. Middle-aged and elderly people, especially those who are frail and sick, are mostly uncomfortable when the season changes. Especially in the cold and summer, the elderly have poor adaptability, and the morbidity and mortality are higher than usual. Special care should be taken.
Complication
Hemorrhagic cerebral infarction Complications upper gastrointestinal bleeding, acne depression, anxiety disorder
1. Pulmonary infection of the lung is one of the main complications, and patients with severe bedridden often have pulmonary infection.
2. Upper gastrointestinal bleeding is one of the serious complications of cerebrovascular disease, namely stress ulcer, the mechanism of which is caused by the inferior colliculus and brain stem lesions. It is now considered to be the anterior and posterior, gray and white knots. The nucleus is associated with the vagus nerve in the medulla, and the autonomic nerve center is in the lower part of the ventricle. However, its high-level center is in the frontal lobe, hippocampus and marginal system. The mechanism of gastrointestinal bleeding is related to the primary or secondary lesions in the above site.
3. Hemorrhoids are mainly a series of manifestations of ischemia and necrosis caused by long-term changes in the body's skin and tissues. The patients with cerebrovascular disease have more limbs, limb paralysis, and prolonged bed rest. Inconvenient to move, it is easy to oppress the bone bulge and other parts, causing local tissue ischemia and hypoxia.
4. Post-cerebral vascular disease depression and anxiety reaction Post-cerebral vascular disease depression is a common emotional disorder of cerebrovascular disease, which should be highly valued in clinical practice.
(1) Characteristic symptoms of depression reaction: 1 bad mood, pessimistic mood, self-feeling bad. 2 sleep disorders, insomnia, dreams or wake up early. 3 loss of appetite, do not think about diet. 4 Loss of interest and pleasure, lack of motivation for anything, lack of vitality. 5 life can not take care of themselves, self-blame and sin, and passively want to die. 6 weight dropped rapidly. 7 low sexual desire, not even sexual desire.
(2) Characteristic symptoms of anxiety response: 1 persistent tension and anxiety. 2 There are also psychological symptoms, such as inattention, memory loss, sensitivity to the sound and easy irritability. 3 At the same time there are physical symptoms, including sympathetic excitability symptoms, such as elevated blood pressure, rapid heartbeat, chest tightness, rapid breathing, irritability, restlessness, and symptoms of parasympathetic excitation, such as polyuria, increased gastrointestinal activity and diarrhea .
Symptom
Hemorrhagic cerebral infarction symptoms Common symptoms Dizziness, intracranial hemorrhage, disturbance of consciousness, meningeal irritation, edema, hypertension, cerebral hemorrhage, high fever, early nausea
1. The general age of onset is more common in elderly patients. First, there is cerebral infarction. Cerebral infarction is more common in a quiet state. Symptoms of cerebral infarction may be conscious, incomplete or complete aphasia, headache, dizziness, vomiting, hemianopia, hemiplegia. , partial sensory disturbance, motor ataxia, incontinence and other neurological symptoms, Liu Zhengsong and other 21 patients with hemorrhagic cerebral infarction, found that from the onset of cerebral infarction to the discovery of hemorrhagic cerebral infarction time: 2 to 7 days 5 For example, 12 cases were 8 to 14 days, and 4 cases were more than 15 days. The general symptoms were aggravated when hemorrhagic cerebral infarction occurred. Among them, 6 cases were aggravated with consciousness disorder, hemiplegia, hemianopia, dizziness, vomiting or ataxia increased in 12 cases. The headache was aggravated and there were 3 cases of localized convulsions.
2. According to the occurrence time of hemorrhagic cerebral infarction
(1) early onset: hemorrhagic cerebral infarction occurred within 3 days after cerebral infarction. According to the literature, early hemorrhagic cerebral infarction after cerebral infarction is often associated with embolic migration. Clinically, neurological symptoms often aggravate and persist. Relieve, and even appear to have disturbances of consciousness, pupillary changes, gastrointestinal bleeding, central hyperthermia and other dangerous symptoms. Brain CT scans show: a bit-like, patchy, ring-shaped, strip-like mixed density shadow in the original low-density infarct Or a mass-like high-density shadow. When the amount of bleeding is large, there is a high-density hematoma image in the low-density area, and there is often a space-occupying effect. There is obvious edema around the lesion. At this time, if there is no CT contrast before the bleeding, sometimes it is very Difficult to distinguish from primary cerebral hemorrhage, the bleeding volume is large, the prognosis is poor, and the mortality rate is high.
(2) Late-onset: Hemorrhagic cerebral infarction occurred 8 days after cerebral infarction. The occurrence of late-onset hair is often related to the establishment of collateral circulation in the infarct area. This type of clinical nervous system symptoms are not obvious, and patients generally do not feel anything. Even the condition gradually improved. The CT scan of the brain showed that there were a bit of shape, patchy, ring-shaped, strip-like mixed density shadow or mass-like high-density shadow in the original low-density infarction. It is easily overlooked by clinicians in clinical practice.
3. According to the clinical symptoms evolved into 3 types
(1) Light type: hemorrhagic cerebral infarction occurs late, more often after 7-8 days of cerebral infarction, some patients occur when the nervous system symptoms are obviously improved, the original nervous system symptoms and signs do not aggravate after hemorrhage, the prognosis is the same The original cerebral infarction.
(2) Moderate: the onset time of hemorrhagic cerebral infarction is 4 to 7 days after cerebral infarction. The neurological symptoms and signs of the original cerebral infarction after hemorrhagic cerebral infarction are not relieved or the condition is aggravated on the original basis. In order to have headache, dizziness, nausea and vomiting, limb sputum aggravation, general unconscious disorder, the prognosis is better.
(3) Heavy: Hemorrhagic cerebral infarction occurred within 3 days of cerebral infarction, and the neurological symptoms and signs of the original cerebral infarction suddenly increased significantly, conscious disturbance, pupillary change, gastrointestinal bleeding, central hyperthermia and other dangerous symptoms. Can die from cerebral palsy.
In patients with cerebral infarction, new neurological symptoms and signs suddenly appear in the stable or improved condition. It is necessary to consider hemorrhagic cerebral infarction. The clinical manifestations of hemorrhagic cerebral infarction have diagnostic value, mainly ache, vomiting, and disturbance of consciousness. Positive meningeal irritation, etc., so in the recovery period of patients with cerebral infarction and sudden changes in the condition, brain CT scan should be done to confirm the diagnosis.
4. The primary disease manifests in the majority of heart disease, such as coronary heart disease, atrial fibrillation, rheumatic heart disease, frequent premature beats of coronary heart disease, myocardial infarction, hypertension, diabetes, hyperlipidemia and other clinical manifestations .
Examine
Hemorrhagic cerebral infarction
1. Cerebrospinal fluid examination is currently not done for cerebrospinal fluid examination, and cerebrospinal fluid examination is not routinely examined as ischemic cerebrovascular disease. Cerebrospinal fluid pressure is often increased in patients with hemorrhagic infarction, erythrocytosis may occur, and white blood cells and phagocytosis may occur in the later stage. The protein content is also elevated and the sugar and chloride are normal.
2. The routine and biochemical examination of hematuria is mainly related to risk factors of cerebrovascular disease such as hypertension, diabetes, hyperlipidemia, heart disease and atherosclerosis.
3. Brain CT scan sometimes has no CT comparison before hemorrhage, it is difficult to distinguish from primary cerebral hemorrhage, clinical manifestations of hematoma type of the original nervous system symptoms are aggravated, hemorrhagic cerebral infarction acute and subacute phase CT High-density shadow, the chronic phase is gradually equal or low-density shadow, there is an enhancement effect, enhanced brain CT scan shows: in the low-density area there is a brain-like or patchy or clump-like enhancement shadow, for the diagnosis is clear It is not recommended to enhance the CT scan of the brain.
Hacke et al. classified the disease into type 4 according to CT findings. 1 Hemorrhagic infarction type I: that is, the density of small spots along the edge of the infarct is increased. 2 hemorrhagic infarction type II: large fused spotted shadow in the infarct zone, no mass effect. 3 brain parenchymal hematoma type I: hematoma mass does not exceed 30% of the infarct area, with a slight mass effect, 4 brain parenchymal hematoma type II: high density of blood clots over 30% of the infarct area, accompanied by significant occupancy effect .
(1) Incidence: Hemorrhagic cerebral infarction is a localized hemorrhage after cerebral infarction, and the incidence rate varies from 3% to 43%, which may be related to regular dynamic CT observation after cerebral infarction. Hemorrhagic brain Infarction is more common in 1 to 2 weeks after the onset of infarction, and most of the infarcts are common, all of which are bleeding in the original infarct and surrounding edema, and more often manifest as the original symptoms and signs, so in the course of treatment, patients with changes should be promptly CT examination, the positive rate of high-density lesions due to CT examination in the early stage of cerebral hemorrhage reached 100%, which is conducive to timely diagnosis and treatment. At the same time, dynamic CT observation of patients with cerebral infarction is also necessary.
(2) Distribution of lesions: Li Wei et al reported 9 cases confirmed by MRI, 39 cases of hemorrhagic cerebral infarction confirmed by CT, brain CT scan or brain MRI examination time was 2 to 21 days, the lesion distribution was: There were 16 cases of parietal lobe, 2 cases of parietal lobe, 8 cases of parietal lobe, 4 cases of occipital lobe, 5 cases of parietal lobe, 8 cases of basal ganglia, 3 cases of thalamus, 2 cases of cerebellum, and the largest dimension of infarct was less than 3cm. 4 cases; 3 ~ 4cm, 10 cases; 4 ~ 5cm, 18 cases; more than 5cm, 16 cases, of which 11 cases of infarction were larger than the ipsilateral cerebral hemisphere 1/2 large area infarction, ventricle compression in 9 cases, Liu Zhengsong 21 cases of hemorrhagic cerebral infarction were reported, 8 cases of large infarction in the middle cerebral artery distribution area, 3 cases of large infarction of cerebellar hemisphere, 10 cases of multiple infarction, and 15 cases of uneven or patchy hemorrhage in hemorrhagic foci. There were 6 cases of hematoma, including 3 cases with blood clots exceeding 30% of the infarct area. There were different degrees of edema around 16 cases of hemorrhage, and there was a mass effect. After treatment, the recovery period was reviewed. CT showed: 12 cases of bleeding showed low density shadow, around No edema, basic absorption, 5 cases of hematoma absorption improved; 2 cases improved after surgery to remove the hematoma, 2 cases of hematoma compared to the original Expand.
(3) Type of performance: 1 non-hematoma type: manifested as secondary high-density shadow in the original infarct area, showing a patchy, patchy, strip-like or annular scattered density density or mass The high-density shadow, the range is less than 2cm × 2cm, the clinical symptoms of the original nervous system are not aggravated. 2 Hematoma type: secondary high-density shadow in the original infarct area is flaky, mass-like, single or multiple hematoma range is more than 2cm × 2cm, hematoma often has a mass effect, obvious edema around the lesion.
4. Brain MRI examination of hemorrhagic cerebral infarction generally does not make MRI diagnosis: 1 acute phase: T1 weighted image is high signal or normal signal; T2 weighted image is slightly low signal change. 2 subacute phase: Both T1 and T2 weighted images are high signal changes. 3 Chronic phase: T2-weighted images are low signal changes.
5. Cerebral angiography Some patients can find occluded blood vessels in the early stage, and the original occluded blood vessels can be re-opened and contrast agent extravasation can be found later.
6. ECG and echocardiography can show atrial fibrillation, frequent premature beats, old myocardial infarction, left ventricular hypertrophy, etc., echocardiography can have heart valve disease, such as rheumatic valvular disease, senile valvular disease.
Diagnosis
Diagnosis and diagnosis of hemorrhagic cerebral
Diagnostic criteria
1. According to clinical manifestations 1 there is a reliable basis for cerebral infarction, especially cardiogenic cerebral thrombosis and large area cerebral infarction, such as brain CT scan or brain MRI. 2 The general nervous system dysfunction is heavier, or progressively worsened, or suddenly worsened after the condition is stabilized. 3 During the application of anticoagulants, thrombolytic drugs or expansion, vasodilator treatment, neurological symptoms aggravated, and even obvious disturbance of consciousness.
2. Imaging examination Imaging examinations such as brain CT scan or MRI examination suggest hemorrhagic infarction.
3. Cerebrospinal fluid examination has elevated intracranial pressure, cerebrospinal fluid has red blood cells, high protein content, normal sugar and chloride.
4. There are primary diseases that cause cerebral embolism such as coronary heart disease, atrial fibrillation, frequent premature beats of coronary heart disease, myocardial infarction, hypertension, diabetes, hyperlipidemia and other clinical manifestations.
5. Exclusion diagnosis excludes intracranial hemorrhagic diseases such as primary cerebral hemorrhage and brain tumor hemorrhage.
Differential diagnosis
Hemorrhagic cerebral infarction also has hemorrhagic lesions on CT findings. It should be differentiated from primary cerebral hemorrhage and brain tumor hemorrhage. Sometimes it is necessary to have a primary CT scan to confirm the diagnosis.
1. Primary cerebral hemorrhage Since the advent of CT, the clinical diagnosis of cerebral hemorrhage is not difficult.
The main clinical basis:
(1) Sudden onset of physical activity or emotional agitation.
(2) rapid onset, symptoms of limb dysfunction and increased intracranial pressure within a few minutes or hours, may have headache, nausea and vomiting.
(3) There are signs of nervous system localization.
(4) History of previous hypertension, especially those who have not undergone regular treatment.
(5) CT scan of the brain: high-density shadow at the time of the disease, surrounding low-density edema zone, there is a mass effect, the hematoma with a diameter greater than 1.5cm can be accurately displayed, the location of the hemorrhage, the size of the hematoma can be determined Whether it breaks into the ventricles, whether there is brain edema and cerebral palsy, almost 100% diagnosis, and hemorrhagic cerebral infarction is the clinical manifestation of cerebral infarction first, and hemorrhagic lesions occur on the basis of cerebral infarction.
2. Patients with brain tumor hemorrhagic brain tumor bleeding usually have headache, nausea, vomiting and other symptoms of increased intracranial pressure, check for optic disc edema and nervous system localization signs, on this basis, the condition suddenly aggravated, brain CT scan shows: The density of cystic changes or necrosis in brain tumors is high, and the blood plane is visible. Sometimes uneven high-density shadows are seen, and the tumor tissue has an enhanced reaction when scanning.
