Hemorrhagic stroke - acute cerebrovascular accident

Hemorrhagic stroke - what is it? Symptoms, treatment and prognosis

Hemorrhagic stroke, acute cerebrovascular accident (ACVA) of the hemorrhagic type is an acute clinical syndrome that is a consequence of damage to cerebral vessels and hemorrhage in the brain. The root cause may be damage to either an artery or a vein. The larger the damaged vessel, the more profuse the bleeding; in severe cases, up to 100 ml of blood is poured into the tissue. The resulting hematoma mechanically compresses and displaces the nervous tissue, and swelling quickly develops in the affected area.

If the victim is not provided with medical assistance within three hours, the chances of survival rapidly decrease and tend to zero. According to statistics, hemorrhagic strokes account for just over 20% of stroke cases.

What it is?

Hemorrhagic stroke is an acute hemorrhage in the brain due to rupture or increased permeability of blood vessels. This cerebrovascular accident differs from classic (ischemic) stroke, which is more common (70% of patients).

The nature of changes in blood vessels during an ischemic stroke is the blockage of their lumen by blood clots, resulting in gradual necrosis of brain cells, and in a hemorrhagic stroke there is a violation of the integrity of the vascular wall, as a result of which the brain tissue is saturated and compressed by the gushing blood.

Hemorrhagic cerebral stroke is a dangerous and insidious disease. It is characterized by:

1. High mortality (60–70% of patients die within the first week after the onset of the disease).
2. Suddenness (in 60–65% of patients, hemorrhage occurs without any previous symptoms).
3. Profound disability of surviving patients - 70–80% of people are bedridden and cannot care for themselves, the remaining 20–30% have a less pronounced neurological deficit (the function of the limbs, walking, speech, vision, intelligence, etc. is impaired)

More than 80% of brain hemorrhages are associated with increased blood pressure (hypertension). By taking antihypertensive drugs (blood-lowering drugs), you can reduce the risk of stroke, the amount of hemorrhage and the severity of brain damage. If patients are admitted to a medical facility within the first 3 hours, this increases the chances of survival. Specialized rehabilitation centers help restore lost brain functions as much as possible after a stroke. Complete cure is rare, but possible.

Differential diagnosis

1 Metastasis

Fig. 23 Melanoma metastases

2 Cavernous angioma

Fig. 24 Cavernoma of the left occipital lobe (native and with intravenous contrast enhancement)

3 Ischemic stroke

A small hematoma can simulate an ischemic stroke on Flair and T2 (Fig. 25a), but the MR signal does not change on DWI (Fig. 25b - it is worth considering that a hematoma in the subacute phase may have a high MR signal on DWI), but on T1 in the subacute phase, the hematoma has an increased T1 MR signal (Fig. 25c).

Fig. 25 Small hematoma in the left cerebellar tonsil.

Classification

It should be noted that a brainstem stroke results in almost instantaneous death. Only in rare cases is it possible to save the patient’s life with such a diagnosis. At the same time, there is no likelihood of returning to a full life.

The brain stem is the center of all body systems and is directly connected to the spinal cord. It serves as a link between the commands of the brain centers and the nerves of the body: it is thanks to it that we are able to move, breathe, swallow, see, hear, and so on. The brain stem also regulates the circulatory system, thermoregulation, and heartbeat. That is why damage to it during a stroke most often leads to death.

Based on their origin, primary and secondary hemorrhagic stroke are distinguished:

Depending on the localization zone, I distinguish the following types of hemorrhagic stroke:

1. Subarachnoid - hemorrhage into the space between the hard, soft and arachnoid membranes of the brain;
2. Hemorrhage on the periphery of the brain or in the thickness of its tissue;
3. Venticular hemorrhage - localized in the lateral ventricles;
4. Combined type: occurs with extensive hemorrhage affecting several areas of the brain.

Peripheral hemorrhage is much less dangerous than intracerebral hemorrhage, which inevitably provokes the formation of hematomas, edema and subsequent death of brain tissue. Hematomas are also distinguished by location:

1. Lobar - the hematoma is localized within one lobe of the brain, without going beyond the cerebral cortex.
2. Medial - hemorrhage damages the thalamus.
3. Lateral – damage to the subcortical nuclei localized in the white matter of the hemispheres (fence, amygdala, caudate, lenticular nuclei).
4. Mixed - hematomas affecting several areas of the brain at once are most common.

Causes of hemorrhage

Hemorrhage due to arterial hypertension

Fig.16

Hemorrhage due to cavernous angioma

Fig.17

Fig.18

Hemorrhage due to cerebral amyloid angiopathy

Fig.19

Clinical manifestations

Symptoms of hemorrhagic stroke are varied and are divided into two large groups: general cerebral and focal. Also, the symptoms strongly depend on the location of the hemorrhage, its size, the somatic condition of the patient and many other factors.

General cerebral symptoms of hemorrhagic stroke include the following:

1. Impaired consciousness (stunning, stupor, coma). The larger the focus, the lower the level of consciousness. However, with damage to the brain stem, even a small focus of hemorrhage leads to severe depression of consciousness.
2. Dizziness.
3. Nausea, vomiting.
4. Headache.
5. General weakness.
6. Breathing disorders.
7. Hemodynamic disorders.

Predominantly focal symptoms include the following:

1. Paresis or plegia in the limbs, hemiparesis is more common.
2. Paresis of facial muscles.
3. Speech disorders develop mainly with damage to the left temporal lobe.
4. Visual impairment (including the development of anisocoria).
5. Hearing impairment.

A stroke should be suspected if the patient has any type of speech impairment, weakness in the arm and leg on one side, the development of epileptic seizures without provoking factors (for example, such factors include alcohol consumption), impaired consciousness up to coma. In any suspicious cases, it is better to play it safe and call an ambulance. Behavior and assessment of the situation when a stroke is suspected should be considered in a separate article.

Rehabilitation in the intensive care unit

12-24 hours after a vascular accident, it is already possible to carry out restoration measures. Before they begin, a test is performed to assess independent swallowing, after which the patient’s feeding method is selected.

The following rehabilitation methods are used during the acute period of a stroke:

• Treatment by position. The position of the patient's head/arms/legs should be changed approximately every two to three hours, as well as turned to the side (if the condition allows it). In order to hold a person in a certain position, bolsters or pillows are used.
• Verticalization - giving the patient an upright position. This can happen passively (with the help of a functional bed or table), passive-active and active. However, to carry out this rehabilitation method, it is necessary to ensure the stability of the circulatory system. More often, verticalization begins in the neurological department.
• Breathing exercises can be carried out in various ways depending on the patient’s condition: vibration with the hands while exhaling, in a position that facilitates breathing, contact breathing (stimulation by touching the hands to the chest) and others.
• Therapeutic gymnastics includes assistance in restoring not only the large muscles of the limbs, but also the muscles of the neck and eyes. At the initial stage, passive gymnastics is performed, when flexion/extension of the patient’s fingers, arms and legs is performed by a qualified physical therapy nurse.

Also during this period, physiotherapeutic treatment is actively used: magnetic therapy, magnetic laser therapy, reflexology, electrical stimulation, darsonvalization and other methods.

Coma due to 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 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:

1. Endo- and exotoxins – derivatives of the end products of metabolism;
2. Oxygen and energy starvation of the brain;
3. Metabolic disorders in brain structures;
4. Expansion of the volume of brain matter.

The most important factors in the development of coma are acidosis, cerebral edema, increased intracranial pressure, and impaired microcirculation of brain fluids and blood.

The state of coma affects the functioning of the respiratory system, excretion (kidneys) and digestion (liver, intestines). It is impossible to recover from a coma at home, and it is very difficult even in intensive care conditions.

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

Treatment

Stroke therapy in the acute period may include:

• Pain relief, correction of body temperature (paracetamol, efferalgan, naproxen, diclofenac, often opiates, propafol). Aspizol, dantrolene are given intravenously, and magnesium sulfate is given by drip.
• Reducing blood pressure, which helps stop bleeding in the brain. For this purpose, drugs are administered intravenously: labetalol, nicardipine, esmolol, hydralazine. However, a sharp decrease in pressure in the first days is not allowed. Next, tablet drugs are prescribed - captopril, enalapril, capoten (as basic therapy orally or through a tube).
• Diuretics for persistent high blood pressure (chlorothiazide, andapamide, Lasix), calcium antagonists (nimotop, nifedipine).
• In case of severe hypotension, vasopressors are prescribed by drip (norepinephrine, mesaton, dopamine).
• Often, a continuous intravenous infusion is used to administer the above drugs, monitoring the pressure level every 15 minutes.
• To reduce cerebral edema, dexamethasone is recommended for 3 days (intravenously). If the swelling progresses, glycerin, mannitol, albumin, and refortan are injected dripwise.
• Often, a continuous intravenous infusion is used to administer the above drugs, monitoring the pressure level every 15 minutes.
• Drugs for the correction of neurological symptoms (sedatives - diazepam, muscle relaxants - vecuronium).
• Local therapy is aimed at eliminating bedsores and includes treating the skin with camphor alcohol and sprinkling with talcum powder.
• Symptomatic therapy - anticonvulsants (lorazepam, thiopental or anesthesia for 1-2 hours), medications for vomiting and nausea (metoclopramide, torecan), against psychomotor agitation (haloperidol). For pneumonia and urological infections, a course of antibacterial treatment is carried out.

In the presence of large hematomas (more than 50 ml), surgical intervention is performed. Excision of the hemorrhage site can be carried out if it is localized in an accessible part of the brain, and also if the patient is not in a comatose state. Most often, clipping of the aneurysm neck, puncture-aspiration elimination of the hematoma, its direct removal, as well as ventricular drainage are used.

Direct surgical removal of hematoma

Direct surgical intervention is used for subcortical hematomas of medium and large sizes, for large hematomas of lateral or mixed localization, accompanied by increasing edema and dislocation of the brain, deteriorating condition of the patient, for cerebellar hematomas. The operation consists of removing the hematoma by encephalotomy, aspiration of blood, removing dense clots with fenestrated tweezers and washing the wound with saline solution. After removing the hematoma, it is necessary to examine its walls and perform thorough hemostasis using coagulation and hemostatic agents. Better results can be achieved by using microsurgical techniques, which can significantly reduce the size of the encephalotomy and thereby minimize surgical brain trauma. For large VMH, accompanied by edema and dislocation of the brain, a wide osteoplastic craniectomy is performed with plastic surgery of the dura mater with periosteum or artificial materials. In case of cerebellar hematomas, it is advisable to supplement direct removal of the hematoma with the installation of external ventricular drainage.

Consequences

If patients can be saved, they experience neurological deficits—symptoms caused by damage to the area of ​​the brain where the hemorrhage occurred.

These may be consequences of a hemorrhagic stroke:

• paresis and paralysis - impaired movement of the limbs on one half of the body, since they are constantly in a half-bent position and it is impossible to straighten them;
• speech impairment and its complete absence;
• mental disorders and irritability;
• constant headaches;
• movement coordination disorders;
• inability to walk or even sit independently;
• visual impairment up to complete blindness;
• facial distortion;
• vegetative state - the absence of any signs of brain activity (consciousness, memory, speech, movements) with preserved breathing and heartbeat.

Symptoms of the disease and their duration depend on the location of the hemorrhage and its volume. The first 3 days are the most dangerous, since during this time severe disorders occur in the brain. Most deaths (80–90%) occur during this period. The remaining 10–20% of patients die within one to two weeks. Patients who survive recover gradually from a few weeks to 9–10 months.

Puncture-aspiration method

It is advisable to use the puncture-aspiration method for small lateral and medial hematomas accompanied by severe neurological disorders. The method consists of puncturing the hematoma with a catheter and simultaneously evacuating the liquid part of the hematoma. For precise positioning of the catheter, it is recommended to use neuronavigation. In some cases, drainage is carried out within 24 hours. The puncture-aspiration method with the introduction of fibrinolytics is indicated for lateral and medial supratentorial hemorrhages of medium size (from 30 to 60 ml) and for cerebellar hematomas (15–30 ml) provided the patient’s condition is stable. In this case, the technique is supplemented by fractional administration of fibrinolytic drugs at certain intervals. In the case of isolated ventricular hemorrhages, external ventricular drainage is performed with fractional intraventricular administration using fibrinolytics. According to the Research Institute of Neurosurgery, this method can reduce mortality in massive IVH by up to 40%, while in the natural course of this disease it approaches 100%.

Left-hand side

If the left side is affected, the consequences are characterized by disruption of the right side of the body. The patient experiences complete or partial paralysis, and not only the leg and arm are affected, but also half of the tongue and larynx. Such patients develop gait disturbances and a characteristic posture of the right hand (folded in a boat).

The victim experiences deterioration in memory and speech, and the ability to clearly express thoughts is impaired. Damage to the left hemisphere of the brain is characterized by problems with recognizing time sequences; it cannot decompose complex elements into components. Impairments in written and oral speech appear.

Right side

If the right side is affected, the most dangerous consequence is damage to the brain stem, in which a person's chances of survival are close to zero. This department is responsible for the functioning of the heart and respiratory system.

Diagnosing a hemorrhagic stroke on the right is quite difficult, since the centers of orientation in space and sensitivity are located in this part. This lesion is determined by speech impairment in right-handed people (in left-handed people the speech center is located in the left hemisphere). In addition, there is a clear relationship: if the functionality of the right half of the brain is impaired, the left side suffers and vice versa.

How long do they live after a hemorrhagic stroke?

The prognosis of hemorrhagic stroke is unfavorable. It depends on the location and extent of the lesion. Hemorrhage into the brainstem is dangerous, which is accompanied by respiratory failure and a sharp, poorly corrected by drugs, decrease in blood pressure to critical levels. Hemorrhage into the ventricles with their breakthrough is severe and often ends in death.

How long do people live with hemorrhagic stroke? This pathology is fatal in 50-90% of cases. Death may occur on the very first day - against the background of generalized convulsions, when breathing is impaired. More often, death occurs later, by 2 weeks. This is due to a cascade of biochemical reactions triggered by the outpouring of blood into the cranial cavity and leading to the death of brain cells. If there is no displacement of the brain, no herniation (entry into a bone hole), no breakthrough of blood into the ventricles, and the compensatory capabilities of the brain are sufficiently large (this is more typical for children and young people), then the person has a great chance of survival.

At 1-2 weeks, in addition to neurological disorders, complications associated with the immobility of the patient, exacerbation of his chronic diseases or connecting him to an artificial respiration apparatus (pneumonia, bedsores, liver, kidney, cardiovascular failure) occur. And if they do not lead to death, then by the end of 2-3 weeks the cerebral edema will stop. By week 3, it becomes clear what the consequences of a hemorrhagic stroke are in this case.

Why do blood vessels rupture?

The main cause is arterial hypertension, especially if untreated or during breaks in taking antihypertensive drugs. The vessels physically cannot withstand the pressure that blood exerts on their walls. A vessel breaks through at the site of thinning or damage, this happens in the presence of an atherosclerotic plaque, congenital aneurysms, head injuries, the use of certain medications that prevent blood clotting, tumors and encephalitis. Another important cause of rupture is arteriovenous malformations, when small arterial and venous vessels do not end in capillaries, but are intertwined into one large ball. Such congenital pathology can be detected during a preventive examination. If a person knows about it, he behaves more carefully and avoids unnecessary risks.

Nature has protected the brain as much as possible from damage, providing it with a mass of protective and backup systems. At a young age they work, but in the second half of life they don’t always work. Therefore, it is advisable that people at risk undergo an annual examination by a neurologist.

At CELT you can get advice from a neurologist.

• Initial consultation – 4,000
• Repeated consultation – 2,500

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The following people are at high risk of developing hemorrhagic stroke:

• hypertensive patients, they need to take medications daily;
• overweight people - the body grows approximately 1 kilometer of blood vessels per 1 kg of excess weight;
• people with high levels of cholesterol, namely low-density lipoproteins, which form atherosclerotic plaques on the vascular wall;
• people who eat insufficient amounts of protein and do not have the “building material” for complete tissue repair;
• those under chronic stress, often suffering from physical or emotional stress;
• alcohol abusers and smokers;
• those suffering from diabetes or heart disease;
• suffering from chronic infections that destroy the vascular wall - lupus erythematosus, vasculitis;
• people who constantly take medications to reduce blood viscosity;
• having direct relatives who died from cerebral hemorrhage.

Recovery after a stroke

The rehabilitation period after a hemorrhagic stroke is long, especially in old age. It depends on the lost functions and does not guarantee their complete rehabilitation. Lost abilities are restored most quickly in the first year after a stroke, then this process is slower. The neurological deficit that remains after three years will most likely remain for life.

Neurologists and rehabilitation specialists are ready to help restore lost functions as much as possible. For this:

• classes are held with a psychologist or psychotherapist;
• if reading/writing skills are lost, classes are held to restore them;
• hydrotherapy is carried out (massage in the pool, light exercises in the water);
• classes on special simulators;
• if speech reproduction is impaired, the person will have to work with a speech therapist; for paresis or paralysis, physiotherapy is carried out (for example, on the Myoton apparatus), massage and exercise therapy are performed with an instructor;
• drugs are prescribed that will help restore lost neural connections (“Cerakson”, “Somazina”), reduce high blood pressure (“Enalapril”, “Nifedipine”), antidepressants and sedatives;
• color therapy - treatment with visual images.

The prognosis for recovery depends on how large the area was covered by the hemorrhage, as well as on how qualified the actions of doctors and rehabilitation specialists were. Hemorrhagic stroke is a very complex pathology, the consequences of which are unlikely to be completely eliminated. Maintenance treatment and rehabilitation continue for a very long time.