Hemorrhagic stroke — spontaneous (not traumatic) hemorrhage in a skull cavity. The term "hemorrhagic stroke" is used, as a rule, for designation of the intracerebral hemorrhage which resulted from any vascular disease of a brain: atherosclerosis, hypertension and amyloid angiopatiya. The most often hemorrhagic stroke arises against the background of the increased arterial pressure. The clinical picture is characterized by the sharp beginning and bystry development of symptoms which directly depend on localization of vascular accident. The hemorrhagic stroke demands urgent haemo static, antigipertenzionny and antiedematous therapy. According to indications surgical treatment is carried out.
Hemorrhagic stroke — spontaneous (not traumatic) hemorrhage in a skull cavity. The term "hemorrhagic stroke" is used, as a rule, for designation of the intracerebral hemorrhage which resulted from any vascular disease of a brain: atherosclerosis, hypertension and amyloid angiopatiya.
Etiology and pathogenesis
Various pathological states and diseases can be the reasons of development of a hemorrhagic stroke: aneurism, arterial hypertension of various genesis, an arteriovenozny malformation of a brain, vaskulit, system diseases of connecting fabric. Besides, hemorrhage can occur at treatment by fibrinolytic means and anticoagulants, and also as a result of abuse of such medicines as cocaine, amphetamine.
Most often the gemmoragichesky stroke happens at an amyloid angiopatiya and a hypertension when there are pathological changes of arteries and brain parenchyma. Therefore intracerebral hemorrhages become result of a hemorrhagic stroke at these diseases most often.
Classification of a hemorrhagic stroke
Intra cranial hemorrhages classify depending on localization of the streamed blood. Distinguish the following types of hemorrhages:
- intracerebral (parenchymatous)
- mixed ( - parenchymatous , parenchymatous , etc.)
Clinical picture of a hemorrhagic stroke
The sharp beginning, most often against the background of high arterial pressure is characteristic of a hemorrhagic stroke. Hemorrhage is followed by a sharp headache, dizziness, nausea, vomiting, bystry development of focal symptoms then the progressing decrease in level of wakefulness — from moderate devocalization before coma development follows. The beginning of subkortikalny hemorrhages can be followed by an epileptiformny attack.
Character of focal neurologic symptoms depends on localization of a hematoma. Among the most frequent symptoms it should be noted a hemiparesis, a frontal syndrome (in the form of violation of memory, behavior, criticism), violations of sensitivity and the speech.
The big role in a condition of the patient right after hemorrhage, and also in the next days is played by expressiveness of the all-brain and dislocation symptoms caused by the volume of an intracerebral hematoma and its localization. In case of extensive hemorrhage and hemorrhage of deep localization in a clinical picture the secondary stem symptomatology is very quickly shown (as a result of dislocation of a brain). At hemorrhage in a trunk of a brain and extensive hematomas of a cerebellum bystry violation of vital functions and consciousness is observed. Heavier than others hemorrhages with break in ventricular system when meningealny symptoms, a hyperthermia, gormetonichesky spasms, bystry oppression of consciousness, development of stem symptoms are shown proceed.
The first 2,5-3 weeks after hemorrhage — the most difficult period of a disease as at this stage weight of a condition of the patient is caused by the progressing brain hypostasis that is shown in development and increase of dislocation and all-brain symptoms. Moreover, dislocation of a brain and its hypostasis — the main reason for death in the sharp period of a disease when to the above-stated symptoms the being available earlier somatic complications join or decompensate (dysfunction of kidneys and a liver, pneumonia, diabetes, etc.). By the beginning of the fourth week of a disease at the survived patients regress of all-brain symptoms begins and to the forefront of a clinical picture there are consequences of focal damage of a brain which will define further degree of an invalidization of the patient.
Diagnosis of a hemorrhagic stroke
The main methods of diagnosis of a hemorrhagic stroke — MRT, spiral KT or usual KT of a brain. They allow to determine the volume and localization of an intracerebral hematoma, extent of dislocation of a brain and the accompanying hypostasis, existence and the field of spread of hemorrhage. Carrying out repeated KT-researches is desirable to track evolution of a hematoma and a condition of brain fabric in dynamics.
First of all, it is necessary to differentiate a hemorrhagic stroke from an ischemic stroke which happens most often (to 85% of total number of strokes). It is not possible to make it according to only one clinical data therefore it is recommended to hospitalize the patient in a hospital with the preliminary diagnosis "stroke". At the same time at the disposal of a hospital there has to be MRT-and the KT-equipment as soon as possible to conduct examination. Among characteristic symptoms of an ischemic stroke it is necessary to pay attention to lack of meningealny symptoms, slow increase of all-brain symptoms. At an ischemic stroke the likvor investigated by means of a lyumbalny puncture has normal structure, at hemorrhagic — in it the content of blood is possible.
Differentiation of intracerebral hematomas of hypertensive genesis from hematomas of other etiology, hemorrhages in the center of ischemia and tumor is necessary. At the same time the age of the patient, localization of a hematoma in brain substance, the anamnesis of a disease are of great importance. Localization of a hematoma in mediobazalny departments of a frontal lobe is typical for aneurisms of a brain/forward connecting artery. At aneurisms of an internal sleepy or average brain artery the hematoma is localized, as a rule, in basal departments by a frontal and temporal lobe, adjacent to a silviyevy crack. By means of MRT it is possible to see aneurism, and also pathological vessels of an arteriovenozny malformation. In case of suspicion on a rupture of aneurism or an arteriovenozny malformation carrying out angiographic inspection is necessary.
Treatment of a hemorrhagic stroke
Treatment of a hemorrhagic stroke can be conservative or surgical. The choice for this or that way of treatment has to be based on results of kliniko-tool assessment of the patient and consultation of the neurosurgeon.
Medicamentous therapy is carried out by the neurologist. Bases of conservative treatment of a hemorrhagic stroke corresponds to the general principles of treatment of patients with any kind of a stroke. At suspicion of a hemorrhagic stroke it is necessary to start holding medical actions as soon as possible (at a pre-hospital stage). At this time the main objective of the doctor is assessment of adequacy of external breath and cardiovascular activity. For correction of respiratory insufficiency carry out an intubation with connection of IVL. Violations of cardiovascular system consist, as a rule, in the expressed arterial hypertension therefore arterial pressure needs to be normalized as soon as possible. One of the major actions which should be held on the arrival of the patient to a hospital — performing the therapy directed to reduction of hypostasis of a brain. For this purpose apply the haemo static medicines and medicines reducing permeability of a vascular wall.
Correcting arterial pressure at a hemorrhagic stroke it is necessary to avoid its sharp decrease as such considerable changes can cause decrease in perfuzionny pressure, especially at an intra cranial hematoma. The recommended level HELL — 130 mm hg. Apply saluretik in combination with osmodiuretika to decrease in intra cranial pressure. At the same time it is necessary to control the level of electrolytes in blood at least two times a day. Except the above-stated groups of medicines, in the same purposes apply intravenous administration of colloidal solutions, barbiturates. Monitoring of the main indicators which characterize a condition of tserebrovaskulyarny system and other zhiznennovazhny functions has to accompany performing medicamentous therapy of a hemorrhagic stroke.
Surgical treatment. The decision on surgical intervention has to be based on several factors — localization of a hematoma, volume of the streamed blood, the general condition of the patient. Numerous researches could not give definite answer about expediency of surgical treatment of a hemorrhagic stroke. According to some researches in certain groups of patients and at certain researches the positive effect of operation is possible. At the same time a main objective of surgery is an opportunity to save the patient's life therefore in most cases operations are performed in the closest terms after hemorrhage. It is possible to delay operation only if its purpose — removal of a hematoma for more effective removal of focal neurologic violations.
At the choice of a method of operation it is necessary to be based on localization and the sizes of a hematoma. So, delete with a direct transkranialny way lobarny and lateral hematomas, and stereotaksichesky as more sparing — in case of the mixed or medial stroke. However after stereotaksichesky removal of a hematoma a recurrence of bleeding arises more often as during such operation the careful hemostasis is impossible. In certain cases a hemorrhagic stroke except removal of a hematoma there is a need for drainage of ventricles (external ventrikulyarny drainages), for example, in case of massive ventrikulyarny hemorrhage or okklyuzionny dropsy (at a cerebellum hematoma).
Forecast and prevention of a hemorrhagic stroke
In general the forecast at a hemorrhagic stroke is adverse. The general percent of lethal outcomes reaches seventy, in 50% death comes after removal of intracerebral hematomas. The main reason for lethal outcomes — the progressing hypostasis and dislocation of a brain, is the reason, the second for frequency, a hemorrhage recurrence. About two thirds of the patients who had a hemorrhagic stroke remain disabled people. The major factors defining a current and an outcome of a disease — the hematoma volume, its localization in a brain trunk, break of blood in ventricles, the violations of cardiovascular system preceding a hemorrhagic stroke and also advanced age of the patient.
The main preventive measures capable to prevent development of a hemorrhagic stroke are timely and adequate drug treatment of a hypertension, and also elimination of risk factors of its development (a hypercholesterolemia, diabetes, alcoholism, smoking).