hypertensive intracerebral hemorrhage
Introduction
Introduction to Hypertensive Cerebral Hemo Hypertensive cerebral hemorrhage (HCH) is a disease with high mortality and disability rate in cerebrovascular disease. Although there have been many medical institutions at home and abroad in the past 100 years, the mortality rate is still high, 3/ More than 4 survivors have different degrees of disability. Often irritated by emotional excitement, excessive excitement, bowel movements, forced breath, or mental stress. basic knowledge The proportion of illness: 0.048% Susceptible population: elderly people with high blood pressure Mode of infection: non-infectious Complications: pulmonary edema shock anemia
Cause
Causes of hypertensive cerebral hemo
Causes
High blood pressure (45%):
Hypertension is the most important cause of hypertensive cerebral hemorrhage. When the blood pressure rises suddenly, the weak wall is prone to rupture and bleeding. Of course, blood pressure is pulsating conduction. After the hemorrhage occurs, a thrombus will form at the rupture of the wall, and the wall will become narrow due to hematoma compression. The blood flow resistance will increase, and the bleeding will stop spontaneously.
Arteriosclerosis (30%):
Arteriosclerosis is a non-inflammatory disease of the arteries that thickens, hardens, loses elasticity, and narrows the lumen of the arterial wall. Arteriosclerosis is a vascular disease that occurs with age, and its regularity usually occurs during adolescence, and it is aggravated and ill in the middle-aged and old age. More men than women, the disease has gradually increased in China in recent years, becoming one of the main causes of death in the elderly. It is also one of the main causes of hypertensive cerebral hemorrhage
Pathogenesis
80% of hypertensive cerebral hemorrhage is on the screen, 20% is under the curtain, and hemorrhage in the cerebral hemisphere is most common in the basal ganglia and hypothalamus, followed by the brainstem and cerebellum. After hemorrhage, hematoma spreads in the direction of white matter fibers. The main effects of the tissue were compression, separation and displacement. The hemorrhage of the nucleus was caused by hemorrhage of the bean-like arteries. The hemorrhage of the lateral bean vein was common, and the hematoma after hemorrhage developed in the direction of the outer capsule. After the hemorrhage of the medial bean vein, it tends to expand toward the internal capsule. The lenticular nucleus is hemorrhagic, and the hematoma tends to be large, which increases the volume of the cerebral hemisphere. The cerebral hemisphere is swollen, the brain is flat, the sulcus is narrow, and the disease side is buckled. Bring back into the cerebral palsy and hippocampus hook back into the cerebellar incision, hippocampus hook back to the brain stem and ipsilateral posterior cerebral artery and oculomotor nerve compression, while the midbrain and pons The position is broken, causing hemorrhage in the midbrain and pons. Sometimes the hematoma develops from the cerebral hemisphere to the medial ventricle and the midbrain. The hematoma can also destroy the caudate nucleus and enter the lateral ventricle, and then flow into the subarachnoid space. Subarachnoid Cavity bleeding, this secondary subarachnoid hemorrhage is mostly concentrated in the middle and lateral pores of the ventral cerebellum and the subarachnoid space in the basal part. If hemorrhage in the cerebellar hemisphere, the hemisphere increases, often pressing the brain stem. It is also easy to break into the subarachnoid space. The thalamic hemorrhage is mostly due to the deep branch of the posterior cerebral arterythe thalamic geniculate artery and the thalamic penetrating artery rupture. The blood can invade into the internal capsule and ventricle after hemorrhage, and the blood of the thalamus invades the ventricle. The rate can be as high as 40% to 70%.
Brain stem hemorrhage is most common in the pons, often expanding from the middle to the sides, or invading the midbrain, often breaking into the fourth ventricle. Cerebellar hemorrhage originates from the dentate nucleus, mainly the upper cerebellar artery hemorrhage, the posterior inferior cerebellum And the cerebellar anterior artery can also be the source of bleeding; after hemisphere hemorrhage, it can cross the midline and affect the contralateral side and invade the fourth ventricle. It is not uncommon to extend to the cerebellum.
Usually, patients with hypertensive cerebral hemorrhage can form a hematoma 20 to 30 minutes after the onset of the disease, and the bleeding gradually stops; 6 to 7 hours after hemorrhage, serum exudation and cerebral edema begin to appear around the hematoma, and this secondary change with time. Increasingly, even a vicious circle occurs. Therefore, the irreversible brain parenchymal damage caused by hematoma is mostly about 6 hours after hemorrhage.
Under the microscope, cerebral hemorrhage can be divided into three phases:
1. Large hemorrhage can be seen in the bleeding period, red blood cells are more complete, the brain tissue of the hemorrhagic foci often appears softened, the nerve cells disappear or change in ischemic changes, the astrocytes also have dendritic destruction, often with polymorphonuclear leukocyte infiltration, Capillary congestion and tube wall swelling, sometimes tube wall destruction and a little bit of bleeding, it should be noted that there is a circle of low-density area outside the high-density area seen by CT examination, which is different from the low-density area around the tumor, not edema Instead, the necrotic tissue is softened. Because the cerebral hemorrhage is mostly arterial rupture, the hematoma is large enough in a short period of time, and the pressure on the surrounding brain tissue is very high, so it is easy to cause necrosis and softening of the brain tissue.
2. Glial cell proliferation can occur 24 to 36 hours after the bleeding in the absorption period, especially the microglia and some cells from the outer cell membrane form lattice cells. In addition to phagocytic lipids, a few lattice cells accumulate hemosiderin. , often gathered in the tablet or around the hematoma, astrocytes also have hyperplasia and obesity.
3. After the recovery of blood and damaged tissue is gradually removed, the defect is replaced by glial cells, glial fibers and collagen fibers to form scars. Those with less bleeding can be completely repaired. If the bleeding is large, the cysts are often left. The same as the softening outcome, the only characteristic is that hemoglobin metabolites remain in the scar tissue for a long time, making the tissue brownish yellow.
Prevention
Hypertension cerebral bleeding prevention
Hypertensive patients should be under the guidance of a physician to control blood pressure and avoid factors such as drastic changes, full meals, strenuous activities, forced bowel movements, and sexual intercourse. If there is severe back pain or pain in the back, sports sensory disturbance, dizziness or syncope, nose bleeding, blurred vision, etc. may be precursors to cerebral hemorrhage, should go to the hospital for examination. The dosage and usage of the above drugs should be in accordance with the doctor's advice.
Most of the cerebral arteriolar lesions associated with hypertension are caused by rupture of blood pressure, which is called hypertensive cerebral hemorrhage. Some patients may have one or both sides of the hands and feet can not move, powerless, or temporarily unable to speak, may have a certain impact in the future life, you must have a correct understanding of your own disease, as long as early drug control, carry out each Functional exercise and language rehabilitation training (such as counting, talking, etc.), and perseverance, this has a positive effect on the rehabilitation of the hands and feet and language function.
Diet to high protein, high vitamins, low fat, light and easy to digest nutritious foods, such as fish, soy products, grains, soybeans, etc., avoid spicy spicy, greasy food (such as strong tea, coffee, fried food), more Vegetables, fruits, keep the stool smooth. If there is facial muscle spasm, you can enter semi-liquid, such as milk paste, porridge, food needs to feed to the healthy side (no face), feeding speed is slow, to avoid coughing, causing suffocation. If the condition is critical and the dysphagia is difficult, the doctor will insert the stomach tube and give the nasal feeding fluid to ensure the nutrient supply.
Complication
Hypertensive cerebral bleeding complications Complications pulmonary edema shock anemia
Including brain-heart syndrome, acute gastrointestinal bleeding, central respiratory form abnormalities, central pulmonary edema and central hiccups, etc., the emergence of these syndromes often affect the prognosis, and severe cases can lead to death, mainly due to Primary or secondary damage occurs in the brain stem, especially in the lower thalamus.
1. Brain-heart syndrome: ECG examination within 1 week after onset, can be found that ST segment is extended or moved down, T wave is low or inverted, and ischemic changes such as QT interval prolongation, in addition, ventricular phase can also occur Pre-contraction, sinus bradycardia, over-speed or arrhythmia, and atrioventricular block, etc., this abnormality can last for several weeks, some people call it "brain-derived" ECG changes, its nature is functional or Organic, there is no unified understanding, the best clinical treatment according to organic lesions, should be given according to changes in ECG, oxygen, taking isosorbide, heart, geranin C and lidocaine At the same time, closely observe the movements of ECG changes in order to deal with them in time.
2. Acute gastrointestinal bleeding: After autopsy and gastroscopy, more than half of the bleeding comes from the stomach, followed by the esophagus, a few are duodenum, gastric ulcers present with acute ulcers, multiple erosions and mucosal or submucosal punctiform hemorrhage The damage is more common within 1 week after the onset of the disease. In severe cases, a large amount of hematemesis may occur within a few hours after the onset of the disease, and a coffee-like liquid is present. In order to understand the situation in the stomach, the stomach tube should be placed 24 to 48 hours after the onset of the coma. Regularly observe the pH of the gastric juice and occult blood at any time. If the pH of the gastric juice is above 5, give 15-30 ml of aluminum hydroxide glue to maintain the pH of 6-7. In addition, give cimetidine nasal feeding or intravenous drip to reduce Gastric acid secretion, the application of omeprazole is better, such as the stomach has bleeding, local application of carbacerol, each time 20 ~ 30ml added physiological saline 50 ~ 80ml, 3 times / d, in addition, Yunnan Baiyao, thrombin can also stomach Internal application, a large number of bleeding should be timely blood transfusion or fluid replacement to prevent anemia and shock.
3. Central respiratory abnormalities: more common in comatose patients, breathing fast, shallow, weak and irregular or tidal breathing, central hyperventilation and apnea, should be inhaled in time for oxygen, artificial respirator for assisted breathing, Appropriate amount of respiratory stimulants such as lobeline or nikethamide can be given. Generally, intravenous infusion is started from a small dose. In order to observe the acid-base balance and electrolyte imbalance, blood gas analysis should be performed in time. If there is any abnormality, it should be corrected.
4. Central pulmonary edema: more common in the acute phase of severe patients, can occur 36h after the onset, a small number of late, pulmonary edema often with the brain changes or aggravated, often one of the important signs of severity The secretions in the respiratory tract should be aspirated in time, and even tracheotomy should be performed to provide oxygen and keep the respiratory tract unobstructed. Some patients may give cardiac medicine as appropriate. Such patients are prone to secondary respiratory infections, so antibiotics should be used prophylactically. Pay attention to the atomization and humidification of the respiratory tract.
5. Central hiccups: Hiccups are common in the acute phase of the disease, mild, occasionally several times, and can be relieved by themselves; severe cases can be persistent and persistent, can interfere with the patient's respiratory rhythm, consume physical strength, and even affect Prognosis, generally can be treated with acupuncture, the drug can be intramuscularly injected with methylphenidate, each time 10 ~ 20mg, can also try clonazepam, 1 ~ 2mg / time, also has a certain effect, but can make sleep deepen or affect the condition Observation, sacral nerve compression often relieves refractory hiccups, and some patients can try traditional Chinese medicine persimmon, cloves and so on.
Symptom
Hypertensive cerebral hemorrhage symptoms Common symptoms Consciousness disorder Deep sensory disorder Coma High fever cerebral hemorrhage Increased intracranial pressure Cerebellar hemorrhage consciousness Fuzzy sensory disorder Deep coma
Hypertensive cerebral hemorrhage occurs most frequently in hypertensive patients aged 50-60 years, usually in emotional excitement, excessive excitement, defecation, exertion of exertion or mental stress. There is often no premonition before cerebral hemorrhage, sudden onset, rapid onset, often in It develops to a peak within a few minutes to a few hours. It is rare to develop to a serious degree after a long course of disease. The clinical manifestations depend on various factors such as the bleeding site, the bleeding range, the body reaction, the general condition, etc., and usually suddenly feel the head when the disease occurs. Department of severe pain, then frequent vomiting, systolic blood pressure of more than 180 mmHg, occasionally convulsions, etc., often in a few minutes or tens of minutes, the mind turned into a coma, accompanied by large, urinary incontinence, such as rapid pulse rate, blood pressure, It is an endangered symptom, and clinically often describes the focal neurological symptoms and signs according to the bleeding site classification.
1. Shell nucleus, basal ganglia hemorrhage: is the most common site of hypertensive cerebral hemorrhage, multiple lesions and internal capsules, patients often have head and eyes turned to the side of the bleeding lesions, showing "gaze lesions" and "three partial" symptoms Hemiplegia, partial sensation of dysfunction and hemianopia, paralysis of the limbs of the bleeding, early muscle tension of the limbs, decreased or disappeared tendon reflexes, and then gradually turned higher, the upper limbs were flexed and adducted, the lower extremities stretched straight, and the tendon reflexes For hyperthyroidism, there may be sputum sputum, pathological reflex positive, typical upper motor neuron hemiplegia, hemorrhoids on the contralateral side of the sensation decreased, acupuncture limbs, no reaction on the face or slower than the other side, such as When the patient is consciously cooperating with the examination, he can also find that the lesion is contralateral and unilaterally blunt. If the hematoma breaks into the lateral ventricle, or even fills the entire lateral ventricle, it is a lateral ventricle cast, and its prognosis is poor.
2. Intracerebral hemorrhage: often suddenly onset, into a deep coma within a few minutes, the condition is critical, pons bleeding often begins with one side of the pons, and immediately spread to both sides, bilateral limb paralysis, most of which is flaccid, a few Sputum or cortical tonic, bilateral pathological reflex positive, bilateral pupils extremely narrowed to "needle-like", its characteristic signs, some patients may have central hyperthermia, irregular breathing, breathing difficulties, often in 1 ~ Death within 2 days.
3. Cerebellar hemorrhage: Light-weight patients are conscious when they are onset, often complaining of severe headache and dizziness in the posterior occipital region, frequent vomiting, ambiguous pronunciation, nystagmus, frequent limbs, but ataxia on the side of the lesion, when the hematoma Gradually increasing into the fourth ventricle can cause acute hydrocephalus. In severe cases, the occipital foramen magnum, the patient suddenly coma, irregular breathing or even stop, and eventually die due to respiratory and circulatory failure.
4. Subcortical hemorrhage in the brain: The symptoms are related to the size of the hematoma. Symptoms such as headache, vomiting, photophobia and irritability are common. The corresponding manifestations of the brain lobe are also prominent. The hematoma is enlarged and the symptoms of the cranial hypertension are obvious.
5. Thalamic hemorrhage: Most patients have coma and hemiplegia after onset, and typical eye signs can appear in the medial or lower thalamic hemorrhage, that is, vertical gaze palsy, mostly upper visual dysfunction, closed eyes in both eyes; eye strabismus, bleeding The lateral eyeball is deflected downward to the medial side; the pupil is reduced, but the pupil is not so large, and the response to light is slow; the eyeball cannot be aggregated and the gaze is disordered, and the bleeding expands outward, which may affect the "three-biased" sign of the internal capsule, and the thalamic hemorrhage may invade the ventricle. Increased severity, high fever, tonic convulsions in the limbs, and increased incidence of visceral syndrome.
6. Subcortical hemorrhage (brain lobe hemorrhage): its incidence rate is second only to basal ganglia hemorrhage, similar to thalamic hemorrhage, the patient's performance varies according to the original blood part, most scholars believe that cerebral hemorrhage occurs in the parietal lobe, The temporal lobe and occipital lobe, the latter part of the brain, have different clinical manifestations of cerebral hemorrhage than basal ganglia hemorrhage. After hemorrhage, the cerebral lobe easily breaks into the adjacent subarachnoid space and is not easily broken into the ventricular system because of the distance from the midline. Therefore, meningeal irritation is mild and the disturbance of consciousness is light, and the prognosis is generally good. The clinical manifestations are:
(1) Consciousness disorders are rare and relatively light.
(2) Hemiplegia and co-directional gaze are less, to a lesser extent, because cerebral lobe hemorrhage does not easily affect the internal capsule as basal ganglia hemorrhage.
(3) meningeal irritation is more common.
(4) occipital lobe hemorrhage may have transient black and cortical blindness, top temporal lobe hemorrhage may have the same hemianopia and hemiparesis, dominant hemisphere may have aphasia, frontal lobe hemorrhage may have mental retardation, urinary incontinence, hemiplegia .
7. Intraventricular hemorrhage is rare in primary intraventricular hemorrhage. Most of the patients are secondary to thalamic hemorrhage or basal ganglia hemorrhage. The clinical manifestations of these patients are closely related to the original blood-staining part, hematoma volume and cerebral ventricle involvement. The closer the part is to the ventricle, the more chances that hemorrhage will expand into the ventricle and invade the ventricle. Therefore, the patients with intraventricular hemorrhage are more serious. In addition to the symptoms of the primary lesion, the brain stem is affected. A series of manifestations of rapid increase in intracranial pressure, more conscious disturbances, significant changes in vital signs, and often accompanied by high fever, tonic attacks.
Examine
Hypertensive cerebral hemorrhage
Hemorrhage enters the subarachnoid space, and secondary subarachnoid hemorrhage may occur. Lumbar puncture may reveal bloody cerebrospinal fluid.
Head CT plain scan is the first choice for examination. It can quickly determine the location, extent and hematoma of the brain, and whether the hematoma breaks into the ventricle, whether it is accompanied by subarachnoid hemorrhage, etc. It can also identify brain edema and cerebral infarction. The bit effect can be inferred by the pressure shift of the lateral ventricle, the displacement of the cerebral palsy and the loss of the basal pool, which contributes to the choice of treatment options and the prognosis. It can also be based on the location of the hematoma and the enhanced CT findings. Identify other causes, such as vascular malformations, aneurysms, tumors, etc.
When the cause of cerebral hemorrhage is suspected to be a factor other than hypertension, MRI is valuable for differential diagnosis of cerebral vascular malformations, tumors, large intracranial aneurysms, etc., but MRI examinations take longer and are more severe. In the case of an acute case, the patient's vital signs and airways must be monitored to prevent accidents. In addition, the MRI manifestations of hematoma in different periods are complicated, and sometimes it is difficult to diagnose.
Cerebral angiography can clearly diagnose aneurysms or vascular malformations, but when cerebral angiography is negative, especially when the hematoma in the brain is large, it should be considered that the ruptured aneurysm or vascular malformation is temporarily compressed and blocked without development; tiny vascular malformations Angiography can also be a false negative.
Diagnosis
Diagnosis and Diagnosis of Hypertensive Cerebral Hemo
diagnosis
The main points for the diagnosis of hypertensive cerebral hemorrhage are: 1 more common in patients with hypertensive arteriosclerosis over 50 years old; 2 often sudden onset during daytime activities; 3 rapid progression of disease, and soon the emergence of complete strokes such as disturbance of consciousness and hemiplegia ; 4 cerebrospinal fluid is homogeneous blood; 5 confirmed by CT or MRI scan.
Differential diagnosis
There are many causes of cerebral hemorrhage differentiated from hypertensive cerebral hemorrhage. It should be differentiated according to the patient's age, past history and imaging examination. Young patients are mostly cerebral vascular malformation bleeding, and the history of chronic hypertension supports hypertensive hemorrhage. Long-term use of anticoagulant drugs or in the course of anticoagulant therapy for myocardial infarction, occasional cerebral hemorrhage, bleeding site is also very important, typical core or thalamic hemorrhage can be identified as hypertensive cerebral hemorrhage; subcortical hemorrhage More suggestive vascular malformations; obvious subarachnoid hemorrhage suggests a large degree of aneurysm, brain metastases, especially melanoma, chorionic epithelial cancer, adrenal cancer, breast cancer, brain metastases of lung cancer and primary brain tumors Glioblastoma, etc. are also prone to spontaneous bleeding, other causes of bleeding are cerebral venous thrombosis, hemorrhage after cerebral infarction, blood disease, arteritis.
