Stroke Center. Brain hemorrhage: how to survive a hemorrhagic stroke Examination plan for hemorrhagic stroke

Many patients after a hemorrhagic stroke have serious neurological disorders that lead to disability. Correct and timely rehabilitation treatment helps to improve impaired functions and ensure a decent quality of life. It should be especially intense in the first 6 months.

The capabilities of the Yusupov hospital allow for effective rehabilitation in the most severe cases. Our doctors use all currently available methods of treatment: drug therapy, physiotherapy, exercise therapy, massage, manual techniques, kinesitherapy, occupational therapy, mechanotherapy.

We use computerized and robotic simulators, verticalizers, which allow you to gradually transfer bedridden patients to a vertical position.

Neurologists, doctors and exercise therapy instructors, neurodefectologists, speech therapists, psychologists, therapists and other specialists work with our patients. Each of them is an expert in their field with extensive clinical experience.

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Prices for the treatment of hemorrhagic stroke

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Stroke is one of the most dangerous diseases for human life and health. This is an acute violation of blood circulation in the brain, accompanied by partial paralysis and loss of consciousness. There are two types of stroke: ischemic and hemorrhagic.

The difference between an ischemic stroke and a hemorrhagic stroke is that in the first case, blood is supplied in insufficient quantities to some parts of the brain. With hemorrhagic, blood rushes to the brain in excessive quantities and, with its pressure, breaks the artery.

Hemorrhagic stroke of the brain is one of the most dangerous pathologies that poses a great threat to the life of the patient. It is less common than ischemic, but much more dangerous than it. In 80% of cases, it leads to disability, in 50%, without timely provision of competent medical care, it leads to death.

More than 40% of patients die from this disease in the first month after an attack and 5-10% during the next year. The attack leads to the appearance of a hematoma in the region of the ventricles of the brain and disturbances in liquorodynamics. This causes cerebral edema and possible death of the patient already in the first hours after the impact. The percentage of those who fully recovered from a hemorrhagic stroke is small, but the chances of successful treatment and rehabilitation remain.

What is a hemorrhagic stroke

Hemorrhagic stroke according to ICD 10 - the International Classification of Diseases - is a rapidly developing serious disease, which more often than others causes the death of the victim. Apoplexy occurs due to rupture of the arteries in the brain against the background of a strong increase in blood pressure. After the blood enters the brain tissue, hematomas are formed - blood clots.

According to ICD 10, hemorrhagic stroke is assigned the code I60-I69 - cerebrovascular disease (CVD). Ischemic is assigned the same code, and these diseases fall under the same classification. But ischemic stroke is less dangerous than hemorrhagic, it differs from the latter in better survival and relapse statistics.

The answer to the question of which stroke is more dangerous - ischemic or hemorrhagic - is obvious: disability in case of hemorrhage is 80%, and the risk of death is very high in the first two days after the stroke.

Expert opinion

Neurologist, Doctor of Medical Sciences

Hemorrhagic stroke is less common than ischemic stroke - 20-25% of cases. Non-traumatic subarachnoid hemorrhage also refers to GI and accounts for about 5% of all cases.

Hemorrhage in the brain usually occurs during the day, against the background of emotional or physical overstrain, develops rapidly, without precursors. The main risk factor for GI is hypertension (8 out of 10 patients had a history of hypertension).

Ischemic stroke has a more favorable prognosis than hemorrhagic, but the latter is not a sentence either. Many myths have gathered around a stroke, and the most important one is that after a stroke, life is over, brain functions are lost, and they cannot be restored. Also, many believe that cerebrovascular accident is a pathology of older age, and young people are not concerned about their lifestyle. However, stroke can be prevented in both young and old age. There are risk factors that we cannot influence, but people are usually aware of their pathologies and treat their health more carefully.

The most important thing to always remember is that if you have cerebral symptoms, you can’t just take them off and stay at home. Be sure to call an ambulance team and carry out diagnostics, at least an MRI. You can't joke with brain diseases.

Classification

There are five types of cerebral hemorrhage, depending on the place of its occurrence:

• parenchymal - intracerebral, characterized by the appearance of focal symptoms (paralysis, speech impairment), and arising in the nervous tissues;
• intraventricular - blood enters the ventricles due to rupture of the vessels in them, in this case the prognosis for the patient is the most unfavorable, since the outflow of cerebrospinal fluid is blocked by blood and cerebral edema occurs;
• subdural - localization of the focus - under the hard shell of the brain;
• epidural - hemorrhage over the hard shell;
• subarachnoid - blood enters the space between the pia mater and arachnoid.

The answer to the question of how a hemorrhagic stroke differs from an ischemic one also lies in the fact that in the first case, swelling of the brain tissue occurs, which begins to put pressure on neurons. They do not receive blood, and they die. Necrosis of nerve cells increases the risk of developing a coma and death.

Coma is not the only prognosis for hemorrhagic stroke. If the patient survives, the risk that the disease will relapse during rehabilitation is very high.

Stages of hemorrhagic stroke

Several changes in the vessel lead to hemorrhage, which can be divided into three main stages:

1. In the lumen of the vessel, blood clots and plaques of cholesterol are formed, and this pathological process leads to the fact that the wall of the artery becomes thinner;
2. Already existing aneurysms are formed or continue to develop - protrusion of the vessel wall;
3. The vascular wall is destroyed and stratified until it is completely ruptured.

These three stages cause hemorrhage in the brain. In hemorrhagic stroke, bleeding is diapedetic, when blood seeps through a thinned vascular wall. In more severe cases, the artery ruptures completely, the blood loss is profuse and leads to the formation of severe hematomas and necrosis of the brain tissue.

Causes and factors in the development of a life-threatening condition

There are several main causes of hemorrhagic stroke. Among them:

• frequent increases in blood pressure (BP);
• diabetes;
• lipid metabolism disorders;
• the presence of excess weight;
• anemia;
• diseases of the cardiovascular system;
• wrong lifestyle and the presence of bad habits.

One of the most common causes of extensive hemorrhagic stroke is arterial hypertension. This is a persistent increase in blood pressure, which leads to a decrease in the elasticity and strength of the walls of blood vessels and a change in the properties of the blood. Rapid filling of vessels with blood over time leads to their rupture and hemorrhage.

Metabolic disorders also affect the condition of the vascular walls. With the pathology of fat metabolism - dyslipidemia - excess cholesterol accumulates in the body. The latter forms deposits on the arteries, due to which their walls wear out and cannot cope with the load. This leads to the development of atherosclerosis - a disease in which the elasticity of the arteries decreases. The diagnosis of this disease means that the patient is at risk of people who are most likely to have a stroke attack.

Diabetes mellitus is a pathology that most often leads to spontaneous hemorrhage. With this disease, frequent fluctuations in blood glucose levels occur. This negatively affects the inner lining of blood vessels and leads to fragility of the walls of the latter. If problems with blood pressure are diagnosed along with diabetes, the artery can rupture in any area. The localization of such a process in the brain is fraught with serious complications.

Lifestyle also greatly affects the state of the walls of blood vessels and the composition of the blood. All strokes, both ischemic and hemorrhagic, occur due to impaired blood supply. Normal blood circulation is possible only with a healthy lifestyle.

With the abuse of alcohol, tobacco products and fatty foods, malnutrition, low physical exertion and the presence of other bad habits, blood viscosity increases. The consequence of this phenomenon is the formation of blood clots, the development of atherosclerosis and other equally dangerous vascular diseases. In such conditions, a stroke often occurs for no apparent reason when the pressure rises.

Less common, but possible causes of the disease:

• neoplasms in the brain;
• congenital aneurysms;
• hypertonic disease;
• blood clotting disorder;
• head injuries and surgeries.

Symptoms of a cerebral hemorrhage

Symptoms of hemorrhagic stroke are divided into cerebral and focal. The first ones include:

• drowsiness or excessive and sudden arousal;
• loss of consciousness and coma;
• Strong headache;
• dizziness;
• nausea and vomiting;
• sweating;
• tachycardia.

The difference between hemorrhagic and ischemic strokes is that ischemic headaches may not be present at all or may be mild and dull. With a hemorrhage in the brain, it is intense and sudden, against its background, the patient experiences vomiting.

In addition to cerebral symptoms, focal symptoms are observed, depending on which part of the brain was affected. If the attack affects the motor cortex located in the frontal lobe, the functions of the motor apparatus are disturbed: the patient cannot move one limb or he has paralysis.

Hemorrhagic stroke affecting the left side of the brain is characterized by:

• partial or complete paralysis of the left half of the body;
• visual disturbances or blindness;
• difficulty swallowing;
• dizziness;
• sleep disorder;
• activity of the speech center only at the initial stage of the attack.

Hemorrhagic stroke on the right side of the brain is characterized by paralysis of the right half of the body, impaired speech functions and sensitivity of the skin. Hemiparesis of the extremities on the left side may form and muscle spasm may occur with the formation of contractures.

Common signs of hemorrhagic stroke are also presented:

• tinnitus due to high blood pressure;
• impaired consciousness;
• loss of ability to navigate in the environment;
• short-term or long-term amnesia.

Diagnosis and differential diagnosis

Diagnosis of hemorrhagic stroke includes a number of primary and additional studies. The key to the diagnosis of hemorrhagic stroke in the clinical setting are CT and MRI. They have high sensitivity and allow you to quickly determine the hemorrhage in the brain.

Prehospital diagnostics

What is really dangerous for a hemorrhagic stroke is the untimely medical care provided. But before you start to provide it, you need to make sure that the person really has an attack:

• ask him to smile - the smile will be crooked;
• ask him a simple question or talk - the patients will not have a coherent speech;
• the patient is unable to raise both arms at the same time;
• other symptoms characteristic of a stroke are present.

Instrumental diagnostics

Instrumental diagnostic tools include:

• CT - X-ray computed tomography, which best determines areas with impaired cerebral circulation;
• MRI - magnetic resonance imaging;
• lumbar puncture: the cerebrospinal fluid will not be colorless, but bloody.

Differential diagnosis of various types of stroke

Ischemic stroke is a severe neuralgic insufficiency. At the onset of an ischemic stroke, the patient has the following symptoms:

• the onset of an attack most often occurs at night or early in the morning, distinctive features in appearance are not noticeable at first;
• later, ischemic focal symptoms are expressed, among which are the inability to move the limbs, dizziness, visual dysfunction, difficulty swallowing, impaired cognitive and logical functions;
• convulsive seizures and motor excitation do not appear.

Hemorrhagic stroke is a circulatory disorder with cerebral hemorrhage, which has a completely different symptomatology and consequences. An attack can be diagnosed by the following signs:

• occurs mainly during the day, after a strong emotional shock or physical exertion;
• changes in appearance become noticeable, excessive sweating and persistent closure of the eyelids, severe redness of the face;
• possible loss of consciousness or coma;
• there are complaints of the patient to a strong, sharp and sudden headache.

meningeal symptoms

Meningeal symptoms are tests that indicate to the doctor the presence or absence of brain damage. Studies are carried out when the patient is in a supine state:

• detection of stiff neck muscles - the tone of the neck muscles increases so much that the patient cannot bring the chin to the chest;
• the patient cannot passively extend the leg when it is bent at the hip joint;
• when pressing on the pubic region, the legs bend at the knees and hip joints;
• when bending the neck in the supine position, the legs involuntarily pull up to the stomach.

Treatment of hemorrhagic stroke

Therapy of the disease includes mandatory phased medical care in the hospital, drug treatment and a rehabilitation course. The success of recovery and the exclusion of relapse will largely depend on the patient himself: maintaining a healthy lifestyle is the most important component of rehabilitation.

First aid to the sick

In order for the prognosis after a hemorrhagic stroke of the brain to be the most favorable, it is necessary to immediately call an ambulance, and if this is not possible, take the person to the hospital on their own as soon as possible. Before the doctors arrive:

• lay the patient so that his head is higher than the body;
• provide fresh air;
• dip the victim's legs in a basin of hot water or give him the pressure pills he usually takes;
• if vomiting begins, turn the victim's head to the side so that he does not choke on the vomit.

Medical therapy

Self-treatment with medicines is prohibited: they are prescribed by a doctor, who also controls their intake. The list of drugs that are prescribed for this disease varies. Rehabilitation may include:

• metabolic agents;
• muscle relaxants;
• antispasmodics;
• hypotonic means;
• vasodilator drugs.

Anticoagulants and nootropics and some other drugs are contraindicated in some cases in the treatment after a hemorrhagic stroke.

Drugs for stroke: Actovegin, Cortexin, Vikasol, Enalapril and others

For the treatment of hemorrhagic stroke and recovery after an attack, patients can be prescribed:

• Actovegin (antihypoxant) - for the treatment of metabolic and vascular disorders of the brain and reducing oxygen starvation of tissues;
• Cortexin - to improve cerebral circulation, to increase the ability to learn, improve memory and thinking;
• Vikasol - prevents the development of bleeding;
• Enalapril - is used to treat arterial hypertension, is effective in heart failure and coronary heart disease.

Operation

Surgical intervention is necessary only in extreme cases, when conservative treatment is ineffective. It is performed to remove hematomas of 30 ml or more. Such an indicator is already considered critical, since such volumes do not resolve on their own. Surgical intervention is also indicated for hemorrhages in the cerebellum, in which neurological symptoms are pronounced.

There are two methods of performing the operation: with endoscopic access and the classical method. Endoscopy is recommended when further full treatment and recovery from an attack is not possible. However, surgery has contraindications. Among them, the presence of medial hematomas and a deep coma in the patient. When performing surgery in such cases, the chance of death for the patient is almost 100%.

Nutrition Features

Treatment of hemorrhagic stroke is impossible without proper nutrition. The diet should be dietary and balanced. The use of caffeine, alcohol, sweets and fatty foods is unacceptable. Drinks should be replaced with natural juices, fruit drinks and herbal teas.

Diet meals should include:

• vegetable oils;
• vegetables and fruits;
• nuts;
• seafood.

Rehabilitation

Treatment and recovery after a hemorrhagic stroke should be started as early as possible, even while the patient is in the hospital. Rehabilitation should include exercise therapy, massage sessions, speech therapy for speech impairments, and the practice of daily fine motor tasks.

It is desirable, if possible, to reduce the time of the patient's stay in the hospital and begin to carry out rehabilitation classes in full. Clinical guidelines for rehabilitation after hemorrhagic stroke, updated in 2018, recommend combining all the methods described below.

Massage, manual therapy and passive exercise

With the help of massage, you can restore the performance of muscle tissues that have been immobile for a long time, strengthen the walls of blood vessels, improve blood circulation and prevent the formation of new blood clots. The possibility of a massage is only in the late rehabilitation period. Procedures must be prescribed by a doctor. He will also determine the techniques that can be used on the affected areas and the duration of exposure to them.

Manual therapy is carried out only locally at first, later you can move on to procedures on the back. The total duration of therapy is no more than 30 procedures, after which a two-month break is required.

Contraindications to massage for the treatment of the consequences of hemorrhagic stroke of the brain:

• fever or blood pressure;
• headache;
• heartache;
• breathing problems.

Passive loads should include:

• imitation of walking: with outside help, grasp the patient's legs, bend and unbend them at the joints;
• circular movements in the elbow and wrist joints;
• development of the shoulder joints.

Therapeutic exercises

The exercise therapy complex is agreed with the doctor, and should include active and passive loads. You can start exercising as early as 5-7 days after the attack. Exercises should be varied, and must be combined with breathing exercises.

The LFC includes:

• exercises for the development of fine motor skills;
• walking training;
• simple flexion and extension of the limbs, their rise;
• slopes.

Physiotherapy

Physiotherapy will help the patient to quickly return to a full life and restore self-care skills. It is aimed at improving motor coordination of muscles, especially in the upper limbs and stimulation of the nervous system, and should include:

• electrophoresis;
• vibrotherapy;
• acupuncture;
• heat therapy with sand, therapeutic mud or paraffin;
• magnetotherapy.

Features of lifestyle after a stroke: physical activity, working conditions, alcohol

It is unacceptable to lead a lifestyle similar to that which was before the rehabilitation period. Physical activity must be present in the life of the patient. Loads should be regular and moderate. You can not engage in weight lifting and do even simple complexes to exhaustion.

After a stroke, it is better to do aerobics: it increases endurance and keeps you in good shape. Classes should begin with a warm-up, then perform a system of simple feasible exercises and do a hitch. If possible, exercise outdoors.

According to statistics, only one in five people who have had a stroke can return to their previous work schedule. The rest receive I-III groups of disability and incapacity for work. If there is an opportunity to return to work, several restrictions on working conditions must be considered. Can't work:

• with toxic substances;
• in rooms with high humidity and temperature;
• in positions associated with strong physical and emotional stress.

Alcohol must be completely eliminated. Strong drinks increase the risk of recurrence of the disease, negatively affect blood pressure, minimize the results of rehabilitation and are incompatible with drug treatment. The same goes for smoking and drinking coffee.

Prognosis of treatment of hemorrhagic stroke

For hemorrhagic stroke with ICD code 10 I60-I69, such consequences are usually characteristic as:

• periodic occurrence of brain crises;
• attacks of sudden weakness;
• speech disorders;
• confusion;
• partial amnesia.

The prognosis after a hemorrhagic stroke will depend entirely on several factors: the timely provision of first aid, the start time of the rehabilitation course and its success, the lifestyle after the attack, and the implementation of relapse prevention measures. Based on the feedback from those who have recovered from a hemorrhagic stroke, it can be concluded that treatment and rehabilitation are successful after an attack.

The first 1-2 days after the attack are considered the most unfavorable for the patient. According to statistics, 50% of patients die at this time due to cerebral edema. At the same time, two out of three patients remain disabled with a high risk of relapse. The prognosis in older people after a hemorrhagic stroke of the brain is worse than in young people:

• at the age of 55-60 years, the probability of death in the first year after the stroke is 30%;
• the risk of recurrence in the elderly is higher than in the young due to the deterioration of the walls of blood vessels;
• there is a risk of death due to complications of the disease: heart problems and kidney failure.

It is impossible to say for sure how long people who have had a hemorrhagic stroke on the left side of the brain live: depending on the consequences of the stroke, even qualified doctors make a diagnosis with caution. But the prognosis of treatment in such patients is better than in those who have experienced a stroke on the right side. In such patients, speech disorders are observed, this is noticed faster and the victims are taken to the hospital faster. The sooner help is provided, the better the prognosis will be.

A hemorrhagic stroke on the right side of the brain means more serious consequences, but how long such people live is also impossible to say for sure. When the right side of the brain is damaged, paralysis of the limbs is observed, which makes treatment difficult. At the same time, the patient partially loses his memory, professional and everyday skills, therefore, even with complex treatment, the prognosis is not very favorable.

The prognosis of treatment and the consequences of hemorrhagic stroke on the right or left side are always individual. They depend on the speed and quality of care, the availability of competent treatment in the recovery period and the patient's healthy lifestyle. The chance of a partial recovery remains, although the quality of life will be lower after rehabilitation.

Bibliography

• ICD-10 (International Classification of Diseases)
• Yusupov hospital
• Clinical neurology with the basics of medical and social expertise. St. Petersburg: Medline-Media LLC, 2006.
• Shirokov, E. A. Stroke, heart attack, sudden death. Theory of vascular catastrophes / E.A. Shirokov. - M.: Quorum, 2010. - 244 p.
• Vilensky, B.S. Stroke: prevention, diagnosis and treatment / B.S. Vilensky. - Moscow: Higher School, 1999. - 336 p.

Hemorrhagic stroke - symptoms, consequences of damage to the right and left sides of the brain

Hemorrhagic stroke (hemorrhoidal) is an acute violation of cerebral circulation with a breakthrough of blood vessels and hemorrhage in the brain. This is the most severe brain accident. It happens spontaneously, moreover, in people over 35 years old and, according to statistics, is among the top five pathologies ending in death. This is explained by the fact that as a result of such a stroke, a hemorrhage occurs in the brain, followed by the formation of edema.

What is a hemorrhagic stroke?

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

Hemorrhagic stroke is an extremely serious disease, often leading to death. This is due to the peculiarity of the cerebral vessels - they do not collapse well, and bleeding when they are damaged is very difficult to stop. Ordinary hemostatic agents do not penetrate the vessels of the brain, but only hematomas are removed surgically, and they are not used to clamp a bleeding vessel.

The trigger mechanism for hemorrhage is a hypertensive crisis, inadequate physical activity, stress, insolation (overheating in the sun), and trauma.

Note! The severity of the condition is determined by the size of the burst vessel, depending on which up to 100 ml of blood can enter the brain. Subsequently, it damages cells, displaces tissues, provokes the development of hematoma and cerebral edema.

Causes

This type of stroke is 8-15%, the remaining 85-92% are ischemic strokes. It can develop at any age (even in children under one year old) and in persons of any gender, but most often it is noted in men 50-70 years old.

In 75 percent of all cases of hemorrhagic stroke, hypertension is the cause.

The causes leading to the development of hemorrhagic stroke are:

• arterial hypertension;
• aneurysms of cerebral vessels;
• arteriovenous malformation of the brain;
• vasculitis;
• amyloid angiopathy;
• hemorrhagic diathesis;
• systemic connective tissue diseases;
• therapy with anticoagulants and / or fibrinolytic agents;
• primary and metastatic brain tumors (in the process of growth, they grow into the walls of blood vessels, thereby causing damage to them);
• carotid-cavernous fistula (abnormal connection between the cavernous sinus and the internal carotid artery);
• encephalitis;
• hemorrhages in the pituitary gland;
• idiopathic subarachnoid hemorrhages (i.e., those hemorrhages in the subarachnoid space of the brain, the cause of which cannot be established).

Factors that cause the progress of the above diseases and increase the likelihood of hemorrhagic stroke:

• Excess weight;
• Unbalanced diet, fatty, meat food;
• Smoking;
• alcohol intake;
• drugs;
• Age, the aging process;
• Craniocerebral and vertebral injuries;
• Sun and heat strokes;
• Long stay in a state of stress, nervous strain;
• Hard physical work;
• Intoxication.

People with an increased tendency to hemorrhagic stroke are at risk for the occurrence of this disease:

According to statistics, mortality in the first month from the onset of the disease reaches 80%, even in countries with a high level of medical development. Survival after hemorrhagic stroke is low and significantly lower than in cerebral infarction. During the first year, 60-80% of patients die, and more than half of the survivors remain permanently disabled.

The most dangerous is a hemorrhage in the brain stem. This structure is directly connected with the spinal cord and controls the basic vital functions: breathing, blood circulation, thermoregulation, heartbeat. A brain stem stroke is often fatal.

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

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

Intracerebral can be located in different areas, which is why this type of stroke is divided into:

• lateral - localized in the subcortical nuclei;
• lobar - in the lobes of the brain, capturing the white and gray matter;
• medial - in the zone of the thalamus;
• mixed - hematomas appear in several places at once.

The following stages of the disease are distinguished:

1. The sharpest. Lasts the first 24 hours from the moment of occurrence of hemorrhage. It is critically important that qualified medical care be provided during this period.
2. Acute. It starts a day after the stroke and lasts 3 weeks.
3. Subacute. It starts on the 22nd day of the disease and lasts up to 3 months.
4. Early recovery. From three months to six months.
5. late recovery. From six months to a year.
6. stage of long-term consequences. It begins a year after the stroke and lasts until the disappearance of its consequences, in some cases for life.

Symptoms and characteristic signs

About an approaching hemorrhagic stroke, symptoms such as:

• severe pain in the eyeballs;
• loss of balance;
• tingling or numbness of the legs, arms, or body parts;
• difficulty understanding speech or slurred speech of the person himself.

Similar signs are observed only in half of patients with hemorrhagic stroke; the same manifestations may indicate a developed ischemic stroke or transient ischemic attack (popularly called a “microstroke”).

A high probability of a hemorrhagic type of stroke is indicated by:

• dizziness;
• Change in skin sensitivity;
• intermittent pulse;
• Flushed face;
• Numbness of one or more limbs;
• persistent headache;
• Attacks of causeless nausea and vomiting that does not bring relief.

Signs of a hemorrhagic stroke in a conscious person:

• Rapidly increasing headache;
• Nausea, vomiting;
• Cardiopalmus;
• Intolerance to bright light, "circles" and "midges" before the eyes;
• paresis, paralysis of the arms, legs, facial muscles;
• Difficult speech.

There are four clearly defined stages of the regression of consciousness:

• Stunning - an incomprehensible look of the patient, a weak response to others;
• Doubtfulness - resembles a dream with open eyes, the gaze is fixed in space;
• Sopor - resembles a deep sleep, a weak reaction of the pupils, a light touch on the cornea of ​​the patient's eye is accompanied by a reaction, the swallowing reflex is preserved;
• Coma - deep sleep, there are no reactions.

In 65-75% of cases, hemorrhagic stroke occurs during the daytime, when a person is most active. It is manifested by a sharp loss of consciousness within a few seconds. During this time, patients only have time to emit a sudden loud cry, which is due to a severe headache, drawing the attention of others. After that, the person loses consciousness and falls.

43-73% of hemorrhages end with a breakthrough of blood into the ventricles of the brain. With a breakthrough of blood into the ventricles, the patient's condition sharply worsens - a coma develops, bilateral pathological signs appear, protective reflexes:

• hemiplegia is combined with motor restlessness of non-paralyzed limbs (violent movements seem conscious at the same time (patients pull a blanket over themselves, as if they want to cover themselves with a blanket),
• hormetonia, symptoms of damage to the autonomic nervous system deepen (chills, cold sweats, a significant increase in temperature occur). The appearance of these symptoms is unfavorable prognostically.

Rupture of a blood vessel and cerebral hemorrhage in hemorrhagic stroke

Focal neurological signs are associated with a malfunction of a certain part of the nervous system. Most often, hemispheric hemorrhages develop, which are characterized by the following symptoms:

• Hemiplegia or hemiparesis - complete or partial loss of motor activity of the arm and leg, develops on the side opposite to the lesion.
• Decreased muscle tone and tendon reflexes.
• Hemihypesthesia - is a violation of sensitivity.
• Gaze paresis - in this case, the eyeballs are directed towards the lesion.
• Mydriasis - this symptom is the expansion of the pupil on the side of the hemorrhage.
• Dropping the corner of the mouth.
• Smoothness of the nasolabial triangle.
• Speech disorders in lesions of the dominant hemisphere.
• Development of pathological reflexes.

The progression of the disease and the appearance of cerebral edema are indicated by:

• manifested strabismus;
• sluggish reaction of pupils to light;
• facial asymmetry;
• change in the rhythm and depth of breathing;
• violation of cardiac activity;
• "floating" movements of the eyeballs;
• severe drop in blood pressure.

A woman had a facial distortion due to a hemorrhagic stroke

The first 2.5-3 weeks after a hemorrhage is the most difficult period of the disease, since at this stage the severity of the patient's condition is due to progressive cerebral edema, which manifests itself in the development and increase of dislocation and cerebral symptoms.

Moreover, dislocation of the brain and its edema are the main cause of death in the acute period of the disease, when the above symptoms are accompanied or decompensated by previously existing somatic complications (impaired kidney and liver function, pneumonia, diabetes, etc.).

Human Consequences

The consequences of a hemorrhagic stroke, if there was an abundant release of blood from the vascular network: the spatial movement of certain structural units of the brain and the mechanical compression of its trunk, a frequent consequence of which is the death of the victim.

If such critical events did not occur, after some time (on average from 1 to 2 weeks) there is a gradual decrease in swelling and a smooth restoration of blood circulation in the brain tissues, but almost always complications after a hemorrhagic stroke persist for life.

The most commonly observed effects are:

• violation of motor functions - lameness, paralysis of the legs or arms. No matter how scary it may sound, but these consequences are among the most acceptable, since they do not entail personality changes or impaired brain functions;
• imbalance of urination and defecation;
• change in perception, development of dementia;
• violation in speech, counting, writing;
• memory impairment, loss of orientation in space and time;
• change in behavioral complexes - suspiciousness, aggression, delayed reaction;
• epilepsy;
• vegetative coma.

After a hemorrhagic stroke of the brain, patients often fall into a coma. This means that a person remains alive, but does not react in any way to external stimuli. Most often, the forecasts of doctors upon the onset of coma are disappointing.

Death

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

• Clear consciousness - up to 20%
• Stun - up to 30%;
• Somnolence (slight clouding of consciousness) - up to 56%;
• Sopor (subcome - deep depression of consciousness) - up to 85%
• Coma - up to 90%.

Hemorrhagic stroke and brain damage on the right and left sides

A hemorrhagic stroke can affect both the left and right sides of the brain. Let's look at what consequences people face when these departments are affected.

Hemorrhagic stroke (bleeding into the brain)

Hemorrhagic stroke (bleeding into the brain and under the lining of the brain) is an acute violation of cerebral circulation, in which intracerebral hemorrhage occurs. Among all strokes, this type occurs in 13-15% of cases. The neurology clinic of the Yusupov hospital uses modern equipment and drugs to diagnose and treat the disease.

Classification of strokes

Hemorrhagic stroke is classified into 2 types of hemorrhage: intracerebral and subarachnoid (under the lining of the brain). In most cases, the occurrence of intracerebral hemorrhage is associated with long-term uncontrolled arterial hypertension. Rarer causes include vascular malformations (abnormal vascular structures), coagulopathy (hemorrhagic diathesis), vasculitis, and brain tumors.

Subarachnoid hemorrhage in 80% of cases is caused by rupture of an intracranial aneurysm. Other possible causes include trauma, intracranial artery dissection, blood disorders, vasculitis, and cerebral vein thrombosis.

Symptoms

Intracerebral hemorrhage usually occurs suddenly, often there is an increase in symptoms within hours or minutes. The clinical picture of a stroke is determined by the location and volume of the hematoma, as well as the degree of increase in intracranial pressure. If you notice the following symptoms, you should immediately call an ambulance!

As a rule, so-called pronounced cerebral disorders (headache, nausea, vomiting, impaired consciousness) occur, which are accompanied by focal neurological symptoms (for example, decreased strength in the limbs on one side, impaired speech or vision). In addition, a neurological examination reveals a meningeal syndrome associated with irritation of the meninges and includes symptoms of muscular-tonic tension, intolerance to bright light, loud sounds, touching the skin, and reactive pain phenomena.

Subarachnoid hemorrhage has a clinical picture similar to intracerebral hemorrhage and is distinguished by the absence of focal symptoms. The first manifestations of a subarachnoid hemorrhage are a sudden, unusually intense headache, dizziness, blackouts, nausea, and vomiting. In a third of all cases, loss of consciousness occurs. A few hours later, meningeal syndromes are detected in patients.

Stroke diagnosis

Diagnosis of hemorrhagic stroke at the first stage includes examination of the patient by a neurologist and computed tomography. If subarachnoid hemorrhage is suspected and neuroimaging is not possible, the diagnosis is confirmed by lumbar puncture and collection of bloody cerebrospinal fluid. As soon as the diagnosis becomes confirmed, the doctor prescribes the necessary treatment. Further diagnostic measures are aimed at identifying the cause of the vascular accident.

Treatment of intracerebral hemorrhage includes the administration of drugs that stabilize blood pressure and hemostatic agents, which helps to stop the hemorrhage. With certain localizations of hematomas, as well as with extensive (more than 40 ml) hematomas, surgical treatment is indicated.

Patients with subarachnoid hemorrhage need early surgical treatment, but if the condition is severe, surgery should be delayed. During the first 3 weeks, there is a high probability of re-hemorrhage, therefore, strict bed rest and maximum rest, as well as the use of drugs that prevent the development of bleeding, are justified.

All types of stroke require rehabilitation therapy aimed at restoring impaired motor and speech functions, psychological and social readaptation. Rehabilitation should be continuous and especially active during the first 6 months after a stroke, when the most intensive recovery of motor and neuropsychological functions occurs.

The Yusupov hospital has all the necessary conditions for the treatment of patients both at the earliest stages of the disease and at a late recovery stage. For each patient, an individual program for treatment and rehabilitation is developed that meets modern standards. Round-the-clock monitoring and care of the patient, together with therapeutic measures, allow achieving successful recovery results in the shortest possible time.

Hemorrhagic stroke: etiology, pathogenesis, clinic, diagnosis, treatment.

A hemorrhagic stroke is a hemorrhage into the substance of the brain, into the ventricles or intrathecal spaces.

Etiology and pathogenesis

The most common cause of cerebral hemorrhage is hypertension and small aneurysms of cerebral vessels. Hemorrhagic strokes can also develop with atherosclerosis, arterial and arteriovenous aneurysms, brain tumors, and vasculitis. There are hemorrhages in the cerebral hemispheres, in the brain stem and in the cerebellum. By localization in the cerebral hemispheres, hemorrhages are divided into lateral - outward from the internal capsule, medial - inside from it and mixed, occupying the entire area of ​​the subcortical ganglia.

In hypertension, the vascular wall of the small arteries of the brain undergoes hyalinization. In atherosclerosis, the deposition of cholesterol leads to a narrowing of the lumen of the vessels and thinning of the vascular wall due to the degeneration of the internal elastic and muscle layers. A constant increase in blood pressure, as well as its periodic rises, can lead to rupture of the altered vessel wall.

Atherosclerotic changes are especially pronounced in large vessels in the places of their bends, turns, where hemodynamic shocks occur. In some cases, the blood flow can exfoliate the damaged area of ​​the intima with the formation of a local protrusion - an aneurysm.

Another important factor in the development of a local lesion of a large artery is the blockage of small vessels that feed its wall (vasa vasorum). Violation of blood circulation in this area leads to necrosis of the intima and muscle layer, followed by the formation of an aneurysm according to the mechanism described above. The cause of hemorrhage may also be spontaneous rupture of congenital arterial or arteriovenous aneurysms.

The clinical picture of intracranial hemorrhage depends on the prevalence of hemorrhage, the presence and localization of intracerebral hematoma. Hemorrhagic stroke is characterized by a sudden onset (often during or after physical exertion, an emotional episode, during vigorous activity, sometimes under the influence of atmospheric conditions) and a rapid increase in depression of consciousness.

With the spread of blood into the basal cisterns, the outflow of cerebrospinal fluid through the subarachnoid spaces is disturbed, which contributes to the formation of cerebrospinal fluid stasis in them and edema-swelling of the brain. Irritation of the interoreceptors of the membranes and walls of the brain vessels by the products of erythrocyte decay causes a pronounced pain reaction, vasospasm and secondary ischemic brain lesions, especially in the hypothalamic region. There are also violations of the blood coagulation system by the type of afibrinogenemia.

In patients with hemorrhagic strokes, changes in the blood coagulation system (coagulation slowdown) are often detected.

Types of hemorrhagic stroke

■ Subarachnoid hemorrhage occurs most often and is clinically characterized by intense headache, often in the fronto-temporal areas, compressive nature, photophobia, pain behind the eyeballs, which are aggravated by their movement. Repeated attacks of vomiting and nausea are possible. Sometimes these manifestations of the disease are mistakenly regarded as symptoms

flu. The general condition of patients is satisfactory or moderate. There is a tendency to rise in blood pressure above normal numbers, tachycardia (up to 80-90 per minute), body temperature rises to subfebrile. At the very beginning of the disease, moderately expressed shell symptoms are detected. With a spinal puncture, blood is found in the cerebrospinal fluid. That gives grounds to make a diagnosis of intracranial hemorrhage.

■ Parenchymal-subarachnoid hemorrhage often develops in people with hypertension and atherosclerosis, is more severe than subarachnoid, since cerebral and focal symptoms are much more pronounced. In a third of such cases, an intracerebral hematoma is formed. Consciousness in patients is disturbed to the level of deafness - stupor, motor excitation often occurs, epileptic seizures are possible. Focal neurological symptoms depend on the location of the hemorrhage. Characterized by high blood pressure and tachycardia (up to 90-110 per minute). Body temperature usually reaches 38-38.5°C. The general condition of patients is moderate or severe. In the general analysis of blood - leukocytosis with a shift of the leukocyte formula to the left. CSF is often bloody, xanthochromic, and rarely normal. CSF pressure is usually elevated.

■ Ventricular-parenchymal-subarachnoid hemorrhage. The patient's condition is severe or extremely severe - often signs of decerebrate rigidity, stem disorders, respiratory disorders of the central type (Kussmaul, Biot, Gaspings) are often detected. There may be a syndrome of "three hemi-" (hemianopsia, hemianesthesia, hemiplegia), often with low muscle tone and bilateral pathological foot signs. When the skin of the trunk and limbs is irritated, hormetonic convulsions often occur with stretching and bringing the upper limb to the trunk. Hemodynamic parameters are characterized by instability, which manifests itself at the beginning as a hypertonic type, and then quickly gives way to their decrease. Consciousness is disturbed to the level of stupor, coma. During spinal puncture, the cerebrospinal fluid is intensely stained with blood. In the clinical analysis of blood - leukocytosis with a shift of the leukocyte formula to the left. With this type of hemorrhage, a pronounced dislocation syndrome quickly develops, circulatory disorders

nia caused by impaired microcirculation in all parts of the brain by the type of arrest of cerebral blood flow. Differential diagnosis of the acute period of strokes Timely diagnosis of hemorrhagic and ischemic strokes (Table 7-1) is important for the appointment of adequate therapy.

Drug treatment of hemorrhagic stroke should be aimed at reducing cerebral edema, headache, autonomic disorders, lowering blood pressure, temperature reaction, eliminating reflex vasospasm, normalizing microcirculation, and eliminating disorders of the blood coagulation system.

A sharp decrease in blood pressure is undesirable, since it can significantly impair blood circulation in the cerebral vessels, especially in conditions of edema and acute intracranial hypertension. In such cases, use bendazol (0.5% solution of 4-8 ml intravenously or intramuscularly), papaverine (2% solution of 2 ml intravenously or intramuscularly), mafusol *, magnesium sulfate, instenon *. You can reduce blood pressure by at least 30% of the initial level. A further decrease can cause a violation of the autoregulation of cerebral circulation.

With a weakening of cardiac activity, a 0.06% solution of corglicon * or a 0.05% solution of strophanthin-K is administered at a dose of 0.25-1 ml with glucose or sodium chloride solution intravenously, nikethamide 1-2 ml subcutaneously, sulfocamphocaine * 2 ml intramuscularly or intravenously. Conducting more vigorous antihypertensive therapy, if necessary, should be postponed until it is achieved.

There is a positive effect of dehydration therapy, which is manifested in an improvement in the state of consciousness and a decrease in stem symptoms. When the patient's condition improves, intravenous or intramuscular administration of 1 ml of a 0.01% clonidine solution can be prescribed. This dose is diluted in 20 ml of physiological sodium chloride solution. In cases of high blood pressure, ganglion blockers can be used: azamethonium bromide 0.5-1 ml of a 5% solution, hexamethonium benzosulfonate 1 ml of a 2.5% solution, or dimecolonium iodide 1 ml. These drugs are administered intramuscularly or intravenously. They can be combined with diphenhydramine 1% solution (2 ml).

As decongestants, only saluretics are administered according to the usual scheme presented in the section on the treatment of ischemic strokes.

In order to increase blood clotting and reduce vascular permeability, calcium chloride is prescribed in the form of a 1% solution, menadione sodium bisulfite 6 ml of a 1% solution intramuscularly, ascorbic acid 5-10 ml intravenously, etamsylate 2 ml intramuscularly or intravenously 3-4 times a day.

In order to reduce the fibrinolytic activity of the blood, substances that inhibit fibrinolysis are used - aminocaproic acid intravenously, 100 ml intravenously with an interval of 3-6 hours. The daily dose of the drug can be 24 g, the course is 5-6 days. Bleeding usually lasts for several minutes. Therefore, it is not necessary to inject hemocoagulants for a long time. To prevent disseminated blood clotting after the introduction of 300 ml of aminocaproic acid, 1.5 ml (5000 IU) of sodium heparin can be intravenously dripped. With severe atherosclerosis, the administration of aminocaproic acid should be refrained from, since thrombotic complications are possible. The appointment of an inhibitor of fibrinolysis aprotinin (trasilol*, contrical*) is indicated. The daily dose of trasylol* is 25,000-75,000 IU intravenously for 4-10 days. Kontrykal* is administered intravenously in drops of 10,000-40,000 IU during the first week of the disease.

In order to relieve spasm, vasodilators, calcium antagonists - nifedipine, nimodipine, which reduce peripheral vascular resistance, as well as drugs that block the activity of serotonin and other biogenic amines, are prescribed.

To relieve irritation of the diencephalic parts of the brain, promethazine 2.5% 2 ml intramuscularly is used. The introduction of this drug must be combined with 50% metamizole sodium (2 ml); at high blood pressure values, ganglion blockers (azamethonium bromide 0.5-1 ml) can be recommended. The combination of these drugs is administered intramuscularly. The frequency of administration is every 4-6 hours. Headache with cerebral hemorrhages, as a rule, is characterized by high intensity, sometimes it is necessary to recommend a 1% solution of trimeperidine (1 ml).

For the purpose of neuroprotection, drugs that do not affect hemostasis are prescribed: cortexin - 20 mg per day, choline alfoscerate - 4 ml per day, actovegin * - 5 ml per day, cytoflavin * - 10 ml per day, ethylmethylhydroxypyridine succinate - according to 4 ml per day, etc.

Lumbar punctures are repeated as rarely as possible due to the risk of increased dislocation, while no more than 2-4 ml of cerebrospinal fluid is removed for laboratory testing.

Patients in the acute phase of cerebral stroke are not given enemas to empty the intestines, since straining during this procedure can lead to an increase in intracranial pressure and provoke re-hemorrhage.

With lateral intracerebral hematomas that do not destroy the internal capsule, their surgical removal is indicated.

A 32-year-old man complains of seizures with loss of consciousness. Six months ago, he had a car accident, lost consciousness for a long time, and he was diagnosed with a brain contusion. Three months ago, the patient first developed a seizure with tonic-clonic convulsions in the limbs, loss of consciousness and urinary incontinence. Similar seizures began to recur every 2 weeks. Neurological examination revealed an increase in tendon reflexes on the left, Babinsky's symptom on the left.

1. Neurological syndrome, type of seizure?

2. Topical diagnosis?

3. Suspected illness?

4. Additional examination methods?

5. Treatment if the suspected diagnosis is confirmed?

3. epilepsy after C-M injury

5. carbamazepine 8-20 mg 1 kg 1 day, valproate 10-50 mg 1 kg 1 day or difenin 5-10 mg 1 kg 1 day; reserve phenobarbital

Hemorrhagic stroke: etiology, pathogenesis, clinic, diagnosis, therapy. Indications for surgical treatment.

Hemorrhagic stroke (HI): hemorrhage in the substance of the brain, parenchymal.

Etiology: hypertension and symptomatic hypertension (kidney disease, tumors), aneurysm rupture or vascular malformation, blood diseases (leukemia, thrombocytopenia), infectious and inflammatory diseases (septic endocarditis, cerebral vasculitis, influenza, syphilis, malaria, sepsis), brain tumors, trauma , but more often hemorrhage in the membranes, cerebral atherosclerosis.

1. vessel rupture (90%), with hypertension, aneurysm, vascular malformation. With a sharp increase in blood pressure → plasma impregnation → the formation of miliary vascular aneurysms → their rupture. More often - in the deep vessels of the anterior, middle and posterior cerebral arteries. Hemorrhage in the cerebral hemispheres or in the cerebellar hemispheres. There is a cavity with blood and clots - it pushes the substance of the brain → hematoma. By localization relative to the internal capsule: lateral from it (lateral hematomas, closer to the cortex, in the subcortical ganglia), medial (medial hematomas, capture the thalamus), mixed.

2. hemorrhage by the type of hemorrhagic impregnation - the mechanism of diapedesis is based on an increase in the permeability of the vascular wall (inflammation, intoxication, blood diseases). There is a tendency to merge foci.

Complications of GI: breakthrough of blood into the ventricles; edema of the GM + edema of the trunk (may be the development of a secondary stem syndrome), dislocation may occur, with wedging into the tentorial or large occipital foramen.

GI clinic: occurs more often during the day, after physical exertion, stress, sudden onset, severe headache (hit), stunning, stupor, coma, psychomotor agitation, nausea, vomiting, flushing / pallor of the face, hyperhidrosis, cold extremities, fever, blood pressure, intense pulse , respiratory distress. Focal symptoms (suppressed against the background of cerebral): hemiplegia, hemiparesis. When the trunk of the GM is compressed: a disorder of consciousness increases, a violation of vital functions, a generalized violation of muscle tone, damage to the nuclei of the cranial nerves (oculomotor and swallowing disorders). With a deep atonic coma, patients usually die (70%). Often meningeal syndrome (after a few hours). With damage to the dominant hemisphere - aphasia, hemiplegia, If lateral hematoma - there may be paresis in the leg and paralysis in the arm, increasing with time. First hypotension, then hypertension. If the hemorrhage in the ventricles is hormetonic convulsions, the cerebral symptoms are not so sharp. Rarely - secondary stem syndrome.

With medial hematoma: sensory disorders (thalamus) + hemiplegia (internal capsule). The course is more severe than with lateral hematoma. Inoperable, unlike lateral.

Breakthrough of blood into the ventricles- a sharp deterioration in the first 5 days: temperature up to 40-42, chills, hormetonic convulsions, deepening of the disorder of consciousness, respiratory distress, unstable blood pressure and pulse, oculomotor disorders, often fatal.

Hemorrhage in the trunk: less often (5%): loss of consciousness, pallor, a sharp drop in blood pressure, severe respiratory and cardiovascular disorders, oculomotor disorders (miosis, immobility or floating movements of the eyeballs, nystagmus), swallowing disorder, bilateral foot signs, bilateral violation of muscle tone (decerebrate rigidity) → atony → death.

Hemorrhage in the cerebellum: sharp pain, dizziness, dysarthria, muscular hypotension, nystagmus, severe respiratory and circulatory disorders, meningeal symptoms, loss of consciousness, often fatal.

Examination: Changes in the blood: leukocytosis, shift to the left, aneosinophilia, lymphocytopenia, protein 1-3 g/l, no color at 3 weeks.

Changes in the cerebrospinal fluid: bloody, xanthochromia, increased pressure, 50-70 erythrocytes,

With echoencephalography: displacement of median structures.

Angiography - clarifies the topic, before the operation.

Computed tomography - in the first hours you can visualize the focus.

Flow: usually poor prognosis at large size. With lateral hematoma, the prognosis is better. From the 3rd week, cerebral symptoms decrease, spastic hemiplegia/paresis is formed.

When diagnosing: relatively young age (45-65 years), an increase in blood pressure in history, the presence of hypertension. Sudden onset during strenuous activity. Significant severity of cerebral symptoms. Changes in the blood, liquor. Early onset of symptoms of trunk damage.

Basic therapy: possible with any NMC: emergency correction of vital functions, relief of homeostasis disorders: reduction of intracranial pressure, correction of water and electrolyte balance and acid-base balance, prevention of secondary infection, relief of vomiting, hiccups, psychomotor agitation, metabolic protection of the brain: drugs with antihypoxic action , antioxidants, Ca antagonists, neurotrophic and membrane stabilizing drugs.

Respiratory disorders: restoration of airway patency, if shortness of breath> 35 → mechanical ventilation.

Hemodynamics: BP control. Don't drop too fast! Reduced by 10% of the existing, after 3-5 days - to the usual numbers. Drugs: beta-blockers (corinfar), ACE inhibitors (captopril, enap), with a significant increase in blood pressure - clonidine, rausedil, diuretics, if persistent blood pressure - ganglioblockers (benzohexonium, pentamine), if low blood pressure polyglucin 400 ml IV drip, glucocorticoids (dexamethasone), strophanthin 0.25%-0.5 ml, dopamine 50 mg in 200 ml of saline slowly intravenously (up to 120 mm Hg).

Epileptic status: seduxen IV 20 mg, after 5 minutes - repeat, if ineffective - sodium oxybutyrate 10 ml-20%, if ineffective - nitrous oxide, hexenal and sodium thiopental are not allowed!

Relief of homeostasis disorders: decrease in intracranial pressure, fight against edema: lasix 20 mg IV and more if necessary, with preserved swallowing - glycerin 1 tablespoon 3-4 times a day through a tube, in severe cases - mannitol IV drip, after 3 hours lasix , albumin 0.5-1 g / kg of body weight, dexamethasone 16 mg per day in 4 divided doses, i.v., i.m.

Maintenance of water and electrolyte balance: accurate accounting of the input and output fluid, control of hematocrit. There may be dehydration - clotting increases, blood supply decreases. With excess water - swelling. Fluid is normal - 35 ml / kg. Per day - for 70 kg - 2500 ml. When the temperature rises, 100-150 ml are added for each degree. If coma, stupor - 50 ml / kg per day. Correction of hyper- or hypoglycemia. For the correction of metabolic acidosis - soda 4% -200 ml.

Pain management: there may be thalamic pain. With GI - headache: analgesics (analgin, ketorol, voltaren, diclofenac). Carbamazepines. With severe pain - non-narcotic analgesics of central action (tramal intravenously, intramuscularly, orally, suppositories). For pain in the limbs - physiotherapy exercises. With increased tone - mydocalm, sirdalut.

Hyperthermia: may be due to secondary infection. It is necessary to exclude aspiration pneumonia, urinary infection - broad-spectrum antibiotics, uroseptics. If central hyperthermia - analgesics, antihistamines.

Relief of psychomotor agitation: Seduxen IV, orally. With inefficiency - sodium oxybutyrate. Antipsychotics - chlorpromazine. Hexenal is impossible! Since the negative effect on the trunk of the GM.

Relief of nausea, vomiting, hiccups: cerucal, metoclopramide, raglan 2 ml, motilium, etapirazine 4-10 mg per day.

Nutrition normalization: on the 2nd day - a nasogastric tube, nutrient mixtures are introduced.

Pelvic organ dysfunction: prozerin, cleansing enema.

Bedsore Prevention: frequent turning of patients, lubrication of the skin, inadmissibility of folds and crumbs on the sheets.

Contracture prevention: the location of the limb in a physiological position. Regular passive movements.

Deep vein thrombosis prevention: small doses of heparin, preferably low molecular weight - fraxiparin 0.3 ml s / c 1 time per day, you can aspirin 125 mg 2 times a day.

Metabolic brain protection: antihypoxants (relanium, encephabol), drugs that stimulate energy metabolism, improve glucose metabolism: nootropics (piracetam). Aminalon, antioxidants - unithiol 5 ml 2 times a day, vitamin E 1 ml IM, emoxipin 5-15 ml IV drip, mexidol, neurotransmitters, neurotrophic and neuromodulatory drugs - glycine 1-2 g per day, Actovigin - improves glucose utilization, immunostimulant, potentiates the action of nootropics, 5-15 ml IV. Contraindicated in diabetes mellitus, pulmonary edema, cerebrolysin - improves glucose transport, oxygen uptake, reduces the action of free radicals. Powerful neuroprotector. From 10 to 30 ml every day in / in drip + isotonic solution in the acute stage.

Differentiated GI therapy:

Stimulation of hemostasis:+ drugs that reduce vascular permeability. By the time of diagnosis, the bleeding has already stopped, and treatment is carried out for changes around the hematoma. For intracerebral bleeding - dicynone (sodium etamsylate) 2-4 ml every 6 hours IM for 6 days, then 2 tablets orally every 6 hours.

Surgery: indications: with a lateral hematoma with a volume of more than 30 ml. If less, conservative therapy is as effective as surgical. Also - if there is depression of consciousness, signs of cerebral edema, secondary stem syndrome, hematoma in the cerebellum. The operation is done through small holes. You can impose external drainage.

Bed rest for at least 2 weeks.

Rehabilitation: after 20 days, the acute period ends. Early recovery period - up to 6 months, late - up to 2 years. More than 2 years is the period of consequences.

In the early recovery period: speech therapy (speech therapist), training of motor functions, exercise therapy, adaptation to a new state, if spasticity - then + muscle relaxation (midakant 1 tablet 2 times a day, serdolite 4 mg 2 times a day), if depression - then + antidepressants, nootropics (piracetam, nootropil), encephabol 100-200 mg 3 times a day, gliatilin 1 g 3 times a day or 1 g 1 time a day IV, then 400 mg tablets 3 times a day, then 2 times a day, cerebrolysin 5 ml IV, 10-20 injections, Semax 2 drops in each nostril 1 time per day for 1 month.

Hemorrhagic stroke

Hemorrhagic stroke- spontaneous (non-traumatic) hemorrhage in the cranial cavity. The term "hemorrhagic stroke" is used, as a rule, to refer to an intracerebral hemorrhage resulting from any vascular disease of the brain: atherosclerosis, hypertension and amyloid angiopathy. Most often, hemorrhagic stroke occurs against the background of high blood pressure. The clinical picture is characterized by an acute onset and rapid development of symptoms, which directly depend on the location of the vascular accident. Hemorrhagic stroke requires urgent hemostatic, antihypertensive and decongestant therapy. According to the indications, surgical treatment is carried out.

Hemorrhagic stroke

Hemorrhagic stroke- spontaneous (non-traumatic) hemorrhage in the cranial cavity. The term "hemorrhagic stroke" is used, as a rule, to refer to an intracerebral hemorrhage resulting from any vascular disease of the brain: atherosclerosis, hypertension and amyloid angiopathy.

Etiology and pathogenesis

The causes of hemorrhagic stroke can be various pathological conditions and diseases: aneurysm, arterial hypertension of various origins, arteriovenous malformation of the brain, vasculitis, systemic connective tissue diseases. In addition, hemorrhage can occur during treatment with fibrinolytic agents and anticoagulants, as well as as a result of the abuse of drugs such as cocaine, amphetamines.

Most often, hemorrhagic stroke occurs with amyloid angiopathy and hypertension, when pathological changes in the arteries and arterioles of the brain parenchyma occur. Therefore, the result of hemorrhagic stroke in these diseases is most often intracerebral hemorrhage.

Classification of hemorrhagic stroke

Intracranial hemorrhages are classified depending on the localization of the outflow of blood. There are the following types of hemorrhages:

• intracerebral (parenchymal)
• subarachnoid
• ventricular
• mixed (subarachnoid-parenchymal-ventricular, parenchymal-ventricular, etc.)

Clinical picture of hemorrhagic stroke

Hemorrhagic stroke is characterized by an acute onset, most often against the background of high blood pressure. Hemorrhage is accompanied by acute headache, dizziness, nausea, vomiting, rapid development of focal symptoms, followed by a progressive decrease in the level of wakefulness - from moderate stunning to the development of a coma. The onset of subcortical hemorrhage may be accompanied by an epileptiform seizure.

The nature of focal neurological symptoms depends on the location of the hematoma. Among the most common symptoms, it should be noted hemiparesis, frontal syndrome (in the form of impaired memory, behavior, criticism), impaired sensitivity and speech.

An important role in the patient's condition immediately after the hemorrhage, as well as in the following days, is played by the severity of cerebral and dislocation symptoms, due to the volume of the intracerebral hematoma and its localization. In the case of extensive hemorrhage and hemorrhage of deep localization, secondary stem symptoms appear very quickly in the clinical picture (as a result of brain dislocation). With a hemorrhage in the brain stem and extensive hematomas of the cerebellum, a rapid violation of vital functions and consciousness is observed. More severe than others are hemorrhages with a breakthrough into the ventricular system, when meningeal symptoms, hyperthermia, hormetonic convulsions, rapid depression of consciousness, and the development of stem symptoms appear.

The first 2.5-3 weeks after a hemorrhage is the most difficult period of the disease, since at this stage the severity of the patient's condition is due to progressive cerebral edema, which manifests itself in the development and increase of dislocation and cerebral symptoms. Moreover, dislocation of the brain and its edema are the main cause of death in the acute period of the disease, when the above symptoms are accompanied or decompensated by previously existing somatic complications (impaired kidney and liver function, pneumonia, diabetes, etc.). By the beginning of the fourth week of the disease in surviving patients, the regression of cerebral symptoms begins and the consequences of focal brain damage come to the forefront of the clinical picture, which will later determine the degree of patient disability.

Diagnosis of hemorrhagic stroke

The main methods for diagnosing hemorrhagic stroke are MRI, spiral CT or conventional CT of the brain. They allow you to determine the volume and localization of intracerebral hematoma, the degree of dislocation of the brain and concomitant edema, the presence and area of ​​distribution of hemorrhage. It is desirable to conduct repeated CT studies in order to trace the evolution of the hematoma and the state of the brain tissue over time.

Differential Diagnosis

First of all, hemorrhagic stroke must be differentiated from ischemic stroke, which occurs most often (up to 85% of the total number of strokes). It is not possible to do this on the basis of clinical data alone, therefore it is recommended to hospitalize the patient in a hospital with a preliminary diagnosis of stroke. At the same time, the hospital should have MRI and CT equipment at its disposal in order to conduct an examination as early as possible. Among the characteristic signs of ischemic stroke, attention should be paid to the absence of meningeal symptoms, the slow increase in cerebral symptoms. In ischemic stroke, the cerebrospinal fluid examined by lumbar puncture has a normal composition, in hemorrhagic stroke, it may contain blood.

It is necessary to differentiate intracerebral hematomas of hypertensive origin from hematomas of other etiologies, hemorrhages into the focus of ischemia and tumors. In this case, the age of the patient, the localization of the hematoma in the substance of the brain, and the history of the disease are of great importance. The localization of the hematoma in the mediobasal parts of the frontal lobe is typical for cerebral/anterior communicating artery aneurysms. With aneurysms of the internal carotid or middle cerebral artery, the hematoma is localized, as a rule, in the basal parts of the frontal and temporal lobes adjacent to the Sylvian fissure. With the help of MRI, you can see the aneurysm itself, as well as the pathological vessels of the arteriovenous malformation. If an aneurysm rupture or arteriovenous malformation is suspected, an angiographic examination is necessary.

Treatment of hemorrhagic stroke

Treatment for hemorrhagic stroke can be conservative or surgical. The choice in favor of one or another method of treatment should be based on the results of a clinical and instrumental assessment of the patient and a consultation with a neurosurgeon.

Medical therapy is carried out by a neurologist. Basics of conservative treatment of hemorrhagic stroke corresponds to the general principles of treatment of patients with any type of stroke. If a hemorrhagic stroke is suspected, it is necessary to start therapeutic measures as soon as possible (at the pre-hospital stage). At this time, the main task of the doctor is to assess the adequacy of external respiration and cardiovascular activity. To correct respiratory failure, intubation is performed with the connection of mechanical ventilation. Disorders of the cardiovascular system are, as a rule, in severe arterial hypertension, so blood pressure must be normalized as soon as possible. One of the most important activities that should be carried out upon the patient's arrival at the hospital is therapy aimed at reducing cerebral edema. For this, hemostatic drugs and drugs that reduce the permeability of the vascular wall are used.

When correcting blood pressure in hemorrhagic stroke, it is necessary to avoid a sharp decrease in it, since such significant changes can cause a decrease in perfusion pressure, especially with intracranial hematoma. The recommended level of blood pressure is 130 mm Hg. To reduce intracranial pressure, saluretics are used in combination with osmodiuretics. In this case, it is necessary to control the level of electrolytes in the blood at least twice a day. In addition to the above groups of drugs, intravenous administration of colloidal solutions, barbiturates are used for the same purposes. Carrying out drug therapy for hemorrhagic stroke should be accompanied by monitoring of the main indicators that characterize the state of the cerebrovascular system and other vital functions.

Surgery. The decision on surgical intervention should be based on several factors - the localization of the hematoma, the amount of blood that has poured out, the general condition of the patient. Numerous studies have not been able to give an unambiguous answer about the advisability of surgical treatment of hemorrhagic stroke. According to some studies in certain groups of patients and in certain studies, the positive effect of the operation is possible. At the same time, the main goal of surgical intervention is the ability to save the patient's life, therefore, in most cases, operations are performed as soon as possible after the hemorrhage. Postponement of the operation is possible only if its goal is the removal of a hematoma for more effective removal of focal neurological disorders.

When choosing a method of operation, one should be based on the location and size of the hematoma. So, lobar and lateral hematomas are removed in a direct transcranial way, and stereotaxically, as more sparing, in the case of a mixed or medial stroke. However, after stereotaxic removal of the hematoma, rebleeding occurs more frequently, since thorough hemostasis is not possible during such an operation. In some cases of hemorrhagic stroke, in addition to removing the hematoma, it becomes necessary to drain the ventricles (external ventricular drains), for example, in the case of massive ventricular hemorrhage or occlusive dropsy (with cerebellar hematoma).

Forecast and prevention of hemorrhagic stroke

In general, the prognosis for hemorrhagic stroke is unfavorable. The total percentage of deaths reaches seventy, in 50% death occurs after removal of intracerebral hematomas. The main cause of deaths is progressive edema and dislocation of the brain, the second most common cause is recurrent hemorrhage. About two thirds of patients who have had a hemorrhagic stroke remain disabled. The main factors that determine the course and outcome of the disease are the volume of the hematoma, its localization in the brain stem, breakthrough of blood into the ventricles, disorders of the cardiovascular system preceding the hemorrhagic stroke, and the patient's advanced age.

A stroke can develop in two ways - ischemic and hemorrhagic. In the second variant, there is a hemorrhage in the brain tissue, which leads to the appearance of an appropriate clinic. It is extremely important to pay attention to such symptoms in time so that timely therapy can be carried out to save the life of the patient.

Hemorrhagic stroke (HI) refers to spontaneous (non-traumatic) intracranial hemorrhage, which is of several types, including intracerebral or parenchymal hemorrhage (ICH), intraventricular hemorrhage (IVH), and subarachnoid hemorrhage (SACH).

Intracerebral hemorrhage is the most common and mainly develops between the ages of 45 and 60 years.

Often, before the development of HI, a person is ill for a long time with hypertension, a blood disease, and cerebral atherosclerosis. If, in addition to this, the patient often experiences emotional or physical overstrain, then the clinic develops against the background of tension.

Video: Hemorrhagic stroke

What is a hemorrhagic stroke?

Hemorrhagic strokes occur when a blood vessel that supplies blood to the brain ruptures and releases blood into the brain tissue. At the same time, brain cells and tissues located below the rupture site may not receive oxygen and nutrients. In addition, bleeding puts pressure on surrounding tissues, causing inflammation and swelling. The development of a hemorrhagic stroke can lead to serious brain damage.

Hemorrhagic strokes fall into two main categories:

1. Intracerebral hemorrhage (intracranial hemorrhagic stroke, ICGI). Bleeding comes from the blood vessels of the brain.
2. Subarachnoid hemorrhage (subarachnoid hemorrhagic stroke, SAHI). The bleeding is in the subarachnoid space, which is located between the brain and the membrane that covers the brain.

Statistics on hemorrhagic stroke

• The estimated incidence of primary intracranial GI is 1-2/100,000 per year in North America.
• ICGI accounts for about half of all stroke cases in children.
• Newborns account for about 20%-30% of all cases.
• Boys are more prone to GI than girls, 60% compared to 40%.
• The main causes of HI include atrioventricular malformations 40%, coagulopathy 20%, cavernous 10%, aneurysm 10%, others 20%.

Causes of hemorrhagic stroke

Causes of cerebral hemorrhage:

• Head injury. Trauma is one of the most common causes of bleeding in the brain in young children.
• High blood pressure. Hypertension is more common in adults, but high blood pressure can occur in infants, children, and adolescents. Blood pressure must be extremely high to cause a hemorrhagic stroke. Most often, this can cause a hemorrhagic stroke, when there is high blood pressure inside a weak or abnormal blood vessel.
• Aneurysm. Pathology is a weakening of the wall of the blood vessel, which swells and bulges. The weakened blood vessel may rupture or leak blood plasma into the surrounding brain tissue, causing a hemorrhagic stroke.
• Tendency to bleed. Hemophilia and sickle cell anemia can cause abnormal bleeding because blood clotting is disrupted. Other conditions, also known as thrombocytopenia, are characterized by low levels of platelets.

Platelets help blood clot and help prevent blood loss when blood vessels are damaged. A lower platelet count can cause massive bleeding into the surrounding tissues, as the body has little ability to form a thrombotic clot that closes the site of injury in the vessel.

• Liver disease. Various inflammatory and infectious diseases of the liver are associated with increased bleeding due to lower levels of clotting factors.
• brain tumors. When a brain tumor begins to bleed, it can cause symptoms similar to those of a hemorrhagic stroke.

Neonatal vitamin K deficiency, arteriovenous malformations (AVMs) may also be the cause.

Genetic syndromes or known mutations contribute to a minority of cases, including the following:

• Coagulopathy (hemophilia)
• Autosomal dominant cerebral cavernomatous malformation
• Hereditary hemorrhagic telangiectasia (HHT)
• Alagille syndrome
• Microcephalic primary dwarfism with cerebral arteriopathy/aneurysms
• Hereditary angiopathy with nephropathy, aneurysm and muscle cramps

Symptoms of a hemorrhagic stroke

With hemorrhagic stroke, various symptoms may occur. Their nature often depends on the type, location of the affected brain, and the underlying cause of the stroke. If large areas of the brain are affected, symptoms may be more severe.

A common initial manifestation of hemorrhagic stroke, especially in children, are convulsions . During seizures, babies may twist their backs and twist their limbs or experience spasms throughout their body. Infants and children may tremble or feel spasms on one or both sides of the body.

Other symptoms of hemorrhagic stroke include extremely severe lethargy and drowsiness , and hemiparesis (unilateral weakness). Older children may experience speech problems or complain of severe headaches.

Additional common symptoms include:

• vomiting;
• convulsions;
• meningeal symptoms;
• fever.

Sometimes the symptoms of a hemorrhagic stroke appear suddenly, but sometimes a hemorrhagic stroke occurs slowly and with a steady deterioration in the patient's condition.

Diagnosis of hemorrhagic stroke

If any symptoms of GI appear, you should immediately call an ambulance or go with the sick by any transport to the nearest hospital.

Diagnosis of hemorrhagic stroke begins with a medical history and physical examination. Health care providers may ask about head trauma or injury, infection, developmental delays, and a family history of bleeding.

An objective examination of the patient may reveal signs of weakness and numbness of the limbs, as well as other symptoms of a stroke.

Laboratory diagnosis of hemorrhagic strokes may include:

• Complete blood count with platelet count.
• Coagulation profile including prothrombin time / partial thromboplastin time.
• Comprehensive metabolic profile when it comes to liver or kidney disease.
• Screening of a rheumatological panel for suspected inflammatory diseases.
• Bacteriological blood test if mycotic aneurysm or other acute inflammatory diseases are suspected.
• Genetic diagnostic studies if there are specific genetically determined vascular syndromes (eg, familial cavernoma, Alagille syndrome).

Imaging studies allow you to visually see the localization of the violation and its size. For this, the following diagnostic methods are most often used:

• Computed tomography (CT) of the head : The method is widely available and provides sensitive and specific diagnostic confirmation of the presence of hemorrhage. This is an important first step in the surgical identification of hydrocephalus, which is a common acute complication of GI. Often, patients have a desire to avoid radiation exposure, so CT is not suitable for such cases. Still, it is the best and fastest way to identify possible neurosurgical emergencies.
• Magnetic resonance imaging (MRI) of the brain : After the initial diagnosis of GI and CT of the head, MRI is usually the next best study to sensitively and accurately characterize the cause of the hemorrhage, as well as the extent and nature of the parenchymal injury. For example, a cerebral cavernoma is best diagnosed with MRI and is not diagnosed with other vascular imaging techniques. Also, the method allows the best identification of small foci of hemorrhage, cardioembolic pathologies and cerebral venous thrombosis, as a common cause of hemorrhage.

• Vascular Imaging : This method is non-invasive and can be combined with MRI in the form of MRI angiography (MRTA) or CT in the form of CT angiography (CTA). It is used as a precursor to catheter angiography and in the planning of stroke surgery. These methods are not sensitive to small aneurysms (
• catheter angiography : This imaging modality is essential for planning surgical treatment and for definitive diagnosis of neoplasms and aneurysms.
• Cranial ultrasonography : often used in neonatal diagnosis when screening is needed with the advantages of a bedside technique.
• transcranial doppler : sometimes used as a baseline study in the presence of signs of vasospasm in the case of an aneurysmal lesion. This method is not widely used in pediatric hospitals because it is technically difficult to perform when diagnosing pathologies in young children.

Treatment of hemorrhagic stroke

The type of treatment will depend on the cause and severity of the stroke, as well as the age of the patient.

Treatment for hemorrhagic stroke most often includes:

• Infusion of fluids to prevent reverse dehydration
• Anticonvulsants for the prevention and control of seizures
• Blood transfusion
• Surgery to control bleeding or relieve pressure on the brain

Treatment of GI in the acute period

The main methods of therapy are aimed at the respiratory tract, the circulatory system. In patients with a depressed mental state, whose general condition deteriorates rapidly, a normal airway passage is ensured and ventilation is controlled. Adequate vascular access is also ensured and perfusion/oxygenation is maintained with fluids and vasopressors as needed.

The hematological status of coagulation is restored with the help of blood products or fresh frozen plasma, and a transfusion can also be performed to normalize the hematocrit.

Anticonvulsant therapy - helps prevent the risk of worsening intracranial hypertension or rebleeding. Continuous electroencephalography (EEG) monitoring may be required at the bedside or if the patient is being treated with neuromuscular blockade.

Treatment of an acute condition aimed at normalizing the functioning of the brain

Intracranial hypertension may require one or more strategies, including:

• external ventricular drainage;
• hematoma evacuation;
• hemicraniectomy;
• hyperosmolar therapy (3% saline).

With subarachnoid HI, control of vasospasm is necessary (careful clinical studies, possibly transcranial Doppler monitoring) and prophylaxis with a calcium channel blocker (nimodipine) for 14-21 days.

Surgical and / or endovascular treatment of vascular anomaly - resection of an aneurysm, resection or embolization of arteriovenous malformation or resection of a cavernoma.

Most veins of Galen arteriovenous malformation are eliminated by embolization.

Inoperable lesions can be treated with radiation therapy - gamma knife or proton beam.

After the treatment of an acute condition, rehabilitation therapy in the intensive care unit begins as soon as possible. Improving the general condition allows you to undergo rehabilitation in a hospital.

Video: Recovery after Hemorrhagic Stroke

Long term treatment

Arteriovenous malformations can re-form/repair, which is associated with a significant risk of re-bleeding. Follow-up catheter angiography is usually performed at regular intervals, approximately 18 years later. MRI angiography and CT angiography are unable to detect small AVMs.

Anticonvulsant treatment can be carried out in several ways. One option is therapy with appropriate drugs for 3-6 months, which allows completion of the initial surgical intervention and rehabilitation. Factors influencing the course of the disease include the presence of a residual or untreated AVM or aneurysm, drug side effects, and the presence of significant epileptiform EEG changes.

Strong psychosocial support for the patient and family is needed, ideally linked to long-term community-based rehabilitation services and individually designed programs.

Possible side effects associated with each treatment option:

Definitive treatment options for the underlying vascular anomalies that cause intracranial GI have certain risks and benefits.

• Surgical resection of an AVM or aneurysm can be successful and life-saving, restoring blood circulation in the brain, but there is a risk of damage to normal vessels and adjacent brain tissues. The estimated risk of rebleeding from an untreated AVM or aneurysm is 4% per year. Some AVMs are located in areas that are inaccessible to surgery, causing serious neurological injury.
• Embolization of an AVM or aneurysm has the advantage that it is less invasive and therefore has fewer risks of damage to normal vessels and brain tissue compared to surgery. But at the same time, there is still a possibility of a violation of the structure of a full-fledged vascular network, and hemorrhagic complications may also occur.
• The advantage of radiation therapy in the treatment of AVMs is that, compared with surgery, the area of ​​damage to adjacent brain tissues is reduced. Such methods can be successful, although a smaller part of the complete cure of the lesion is determined, so it often takes 12-18 months to achieve the intended effect of therapy.

Additionally, many patients cannot tolerate the effects of radiation toxicity.

Prognosis of hemorrhagic stroke

Predictive findings for intracranial GI vary widely. Panel studies report results as follows:

• Mortality: mortality rate from 7% -50%, that is, on average, is about 25%, in studies for the 1970s - 2004. In the most recent group studies with aggressive surgery, mortality is in the lower part of this range.
• Neurological status of survivors: with a “good” result, about 30%-50% of patients are reported to have survived.
• Long-term illnesses that occur after GI include chronic headache and epilepsy, although the rates of these problems are not well characterized.

Factors associated with a greater risk of poor outcome include a large volume of hemorrhage (>2% of total brain volume) and a depressed mental status on examination.

Prevention of hemorrhagic stroke

There are no proven or accepted methods for screening and preventive treatment of GI, other than addressing the conditions that predispose to its development. Most cases of AVMs and aneurysms are isolated and non-syndromic, so they are asymptomatic until they present with hemorrhage.

For known genetic syndromes associated with aneurysms, AVMs, etc., there is no definitive proven strategy for visual surveillance or presymptomatic surgical or endovascular therapy. Such decisions are made on a case-by-case basis under the guidance of individual practitioners.

Video: Hemorrhagic stroke. Hemorrhage in the brain

Hemorrhagic stroke clinic

The clinical manifestations of hemorrhagic stroke and ischemic stroke differ from each other. A feature of hemorrhagic stroke is that it usually develops suddenly, during the day, at the time of physical or emotional stress, more often in people of working age (from 45 to 60 years). In some cases, the development of a hemorrhagic stroke is preceded by a growing headache, a feeling of a rush of blood to the face, vision of objects in red or "as if through a fog." However, more often the onset of the disease is acute, without precursors; there is a sudden headache (“like a blow”), the patient loses consciousness, falls. At the same time, vomiting and psychomotor agitation are noted. The depth of impaired consciousness in this type of stroke is different - from stunning, stupor to coma. In many patients with hemorrhagic stroke, in addition to cerebral, meningeal (meningeal) symptoms are noted, the severity of which depends on the location of the stroke. Depending on the type of hemorrhage, the severity of meningeal symptoms varies: with subarachnoid hemorrhage, they may prevail, with parenchymal hemorrhage, they may be very moderately expressed or absent. Hemorrhagic stroke is characterized by the early appearance of pronounced vegetative disorders: facial flushing, sweating, fluctuations in body temperature. Blood pressure in this type of stroke, as a rule, is elevated, the pulse is tense. Respiration is disturbed and has features: it can be frequent, snoring, stertorous or periodic of the Cheyne-Stokes type, with difficulty in inhaling or exhaling, of different amplitudes, rare.

Simultaneously with the above manifestations, focal symptoms can be observed, the features of which are determined by the localization of the hemorrhage. With the localization of blood

effusions in the hemispheres, as a rule, hemiparesis or hemiplegia is detected on the side opposite to the affected hemisphere, muscle hypotension or early muscle contracture in the affected limbs, hemihypesthesia, as well as paralysis of the gaze with eye aversion to the side opposite to the paralyzed limbs (the patient "looks at the affected hemisphere" ). If mild disorders of consciousness are detected, hemianopsia, aphasia (with damage to the left hemisphere), anosognosia and autotopognosia (with damage to the right hemisphere) can be detected. When examining a patient in a coma, contact with him is impossible, there is no reaction to irritation, so the following signs should be considered:

• unilateral mydriasis, which can be determined on the side of the pathological focus, abduction of the eyes towards the focus;

If extensive intracerebral hemispheric hemorrhages are formed, they are often complicated by a secondary stem syndrome: disturbances of consciousness deepen, oculomotor disorders appear, the reaction of pupils to light weakens and disappears, strabismus develops, “floating” or pendulum movements of the eyeballs, hormetonia, decerebrate rigidity, possibly violation of vital functions (progressively worsening breathing, cardiac activity). Secondary stem syndrome can occur both immediately after a hemorrhagic stroke, and after some time.

For a stroke localized in the brain stem, initial signs of pathology of respiration and cardiac activity, symptoms of damage to the nuclei of cranial nerves, conduction motor and sensory disorders are characteristic. With this topic of the lesion, the symptoms can manifest themselves in the form of alternating syndromes, bulbar paralysis. In some cases, hemorrhage in the brainstem can be manifested by tetraparesis or tetraplegia. Nystagmus, anisocoria, mid-Riasis, fixed gaze or "floating" movements of the eyeballs, swallowing disorders, cerebellar symptoms and bilateral pathological pyramidal reflexes are very often observed. With a hemorrhage in the pons of the brain, the following symptoms are determined: miosis, paresis of the gaze with averting the eyes towards the focus (“the patient looks at the paralyzed limbs”). Hemorrhages in the oral parts of the brain stem are characterized by an early increase in muscle tone with the development of hormetonia, decerebrate rigidity; with damage to the caudal sections, early muscular hypotonia or atony is noted.

Hemorrhage in the cerebellum is characterized by systemic dizziness with a sensation of rotation of surrounding objects, headache in the back of the head, sometimes pain in the neck, back, and in some cases, repeated vomiting. Neck stiffness, diffuse muscular hypotension or atony, ataxia, nystagmus, and slurred speech may develop. In a number of cases, with hemorrhagic stroke localized in the cerebellum, oculomotor disorders are observed: Hertwig-Magendie symptom, Parino syndrome, etc. It has been established that focal neurological symptoms are masked by severe cerebral symptoms in the case of lightning-fast development of hemorrhage in the cerebellum.

A breakthrough of blood into the ventricles of the brain is manifested by a sharp deterioration in the patient's condition: disorders of consciousness increase, vital functions are disturbed, hormetonia is determined with an increase in tendon and the presence of pathological reflexes, vegetative symptoms are aggravated (chill-like tremor and hyperthermia occur, cold sweat appears).

Sometimes with subarachnoid hemorrhage, damage to the cranial nerves is detected, more often the oculomotor and optic nerves.

The subacute form of hemorrhagic stroke is characterized by an even slower increase in symptoms and is usually caused by diapedetic hemorrhage in the white matter of the brain or venous bleeding.

In the elderly, the course of hemorrhagic stroke is often subacute. In this category of patients, focal symptoms predominate, cerebral symptoms are less pronounced, and meningeal symptoms are often absent. This is due to an age-related decrease in brain volume and an increase in the volume of its ventricular system, as well as a decrease in the overall reactivity of the body.

The course of the clinical picture of hemorrhages in the substance of the brain is divided into three periods:

• spicy;

Acute period manifested by pronounced cerebral symptoms, sometimes completely masking focal symptoms. Most often, the cause of hemorrhage is emotional or physical stress. The disease begins acutely, during the day, without precursors, with apoplektiform development of a coma, which is characterized by a complete loss of consciousness, loss of response to external stimuli, loss of active movements and dysregulation of vital functions.

When examining a patient, wide pupils that do not respond to light are determined, there is anisocoria with pupil dilation on the side of the focus. The corner of the mouth is lowered, the nasolabial fold on the side of the lesion is smoothed out, the cheek "sails" when breathing. There are pronounced vegetative disorders. The face is often purple-red, but sometimes sharply pale. Vomiting is often observed. Respiratory failure is detected: it can be hoarse, periodic, such as Cheyne-Stokes, with difficulty inhaling or exhaling. From the side of the cardiovascular system, the following changes can be detected: the pulse can be slowed down or quickened, blood pressure is usually high - from 26.7 / 13.3 (200/100 mm Hg) to 40.0 / 24 .0 kPa (300/180 mmHg). There is a violation of the regulation of the pelvic organs: involuntary urination and defecation. Already on the 1st-2nd day, the so-called "central hyperthermia" may develop with an increase in body temperature up to 40-41 ° C, on the 2nd-3rd day pneumonia may develop (especially often on the paralyzed side) or pulmonary edema. Patients with a stroke may develop bedsores in the region of the sacrum, buttocks, and heels. In addition to the listed signs, in patients with hemorrhagic stroke, due to swelling of the brain and its membranes, various manifestations may develop: neck stiffness, as well as symptoms such as Kernig's, Brudzinsky's and other meningeal symptoms. A characteristic sign of hemorrhagic stroke is the appearance on the fundus of hemorrhage (in the form of stripes, "puddles"), located mainly along the vessels.

Paraclinical examination reveals a number of deviations from the norm in this type of stroke. In the general blood test, leukocytosis is detected in the range of 10-109 - 20-109 in 1 l, as well as relative lymphopenia (0.08-0.17). In the general analysis of urine, low relative density, protein, sometimes erythrocytes and cylinders are determined. In severe hemorrhages in the biochemical blood test, the glucose content rises to 8.88-9.99 mmol / l. It is noted that glucose can also appear in the urine. This must be taken into account, since the occurrence of glycosuria and hyperglycemia in patients with hemorrhagic stroke is not a sufficient basis for diagnosing diabetes mellitus. In hemorrhagic stroke, residual nitrogen in the blood is normal or slightly higher than normal.

In the study of cerebrospinal fluid (cerebrospinal fluid), its increased pressure is determined. A few hours after hemorrhage, erythrocytes are found in the cerebrospinal fluid, the number of which depends on the proximity of the hemorrhage focus to the CSF pathways. During the course of parenchymal hemorrhage, together with ventricular or subarachnoid cerebrospinal fluid, it is intensely bloody. It increases the protein content to 1000-5000 mg/l and cells. Lymphocytic and neutrophilic pleocytosis is estimated in tens or hundreds.

The electroencephalogram reveals the disappearance of the normal a-rhythm, the appearance of slow waves such as theta and d-waves with high amplitude. When monitoring the biopotentials of the brain of such patients, their changes are diffuse in nature, noticeable local disturbances and even interhemispheric asymmetry are usually not detected.

When conducting rheoencephalography, characteristic changes are also revealed on the side of the focus.

Regular changes are also determined on the echoencephalogram: the median echo can be shifted by 6-7 mm to the side opposite to the hemorrhagic focus.

During angiography, characteristic displacements of the anterior and middle cerebral arteries and their branches, deformation of the internal carotid artery and the presence of an avascular area in the hematoma area are revealed.

The prognosis for hemorrhage in the ventricles of the brain is difficult, only in isolated cases, surgical treatment saves the life of this category of patients. They die from cerebral hemorrhage most often on the 1st or 2nd day of the disease, as there is destruction, swelling or compression of the vital centers of the brain stem.

As the swelling of the brain decreases and hemodynamics improves in areas of the brain not affected by hemorrhage, reparative processes gradually begin. The symptomatology of movement disorders is subject to modification depending on the period elapsed after a stroke. At the very beginning, voluntary movements are completely lost, but later hemiplegia turns into hemiparesis with a predominance of damage to the distal extremities.

Restoration of movements in patients who have had a hemorrhagic stroke begins with the leg, then the arm. It is important to note that movements begin to recover from the proximal limbs. After a few days after the stroke, the restoration of muscle tone of the paralyzed limbs begins. At the same time, the tone of the flexor muscles increases in the upper limbs, and the extensor muscles in the lower limbs, the Wernicke-Mann position occurs. Such an uneven increase in the tone of the flexor and extensor muscles in the future can lead to the formation of flexion and extensor contractures. At the beginning of the process of restoration of temporarily lost reflexes, pathological reflexes of the extensor type appear (symptoms of Babinsky, Oppenheim, Gordon, Schaefer), and then the flexion type (Rossolimo, Zhukovsky, Bekhterev).

In this period, clonuses of the foot, patella, and hand appear. There is not only an increase in reflexes, but also their perversion, there are protective reflexes, synkinesis.

In addition to the restoration of movements, there is a restoration of other impaired functions, such as sensitivity, vision, hearing, mental activity, etc. The recovery period, as a rule, lasts from several months to several years.

Hemorrhagic stroke: clinic and diagnosis

Hemorrhagic stroke is an acute violation of the blood supply to the brain, which develops as a result of rupture of an artery and hemorrhage in the brain tissue or subarachnoid space. This ailment belongs to the group of cardiovascular diseases, and its development is most often due to previous vascular pathology, hypertension, or a violation of the blood coagulation system.

hemorrhagic stroke. Clinical picture

A distinctive feature of this type of stroke is a sudden onset, which, as a rule, is closely related in time to an episode of physical or psycho-emotional overstrain. For this pathology, it is characteristic that the patient can very accurately (up to a minute) name the time of the onset of the first symptoms, and the onset of the disease is often described by him as a “hit”.

Hemorrhagic stroke of the brain most often debuts with a sudden and very severe headache. . A person describes this pain as excruciating, throbbing, its distinctive feature is resistance to various analgesics - it is impossible to stop a headache during a stroke at home.

Soon, uncontrollable vomiting, as well as confusion, can join the headache - with a diagnosis of stroke, hemorrhagic coma develops in a significant percentage of cases. However, loss of consciousness does not always accompany this vascular pathology. In some cases, at the onset of the disease, there is a general excitation of the patient and an increase in motor activity.

Hemorrhagic stroke is often accompanied by meningeal symptoms. . namely stiff neck and other symptoms of irritation of the meninges. These symptoms are invariably present with subarachnoid hemorrhage and may be absent with intracranial hemorrhage.

Above, we described the cerebral symptoms of hemorrhagic stroke. As the brain damage progresses, focal symptoms join them, which is the appearance of a neurological deficit caused by the loss of functions of the affected parts of the brain.

In the group of focal symptoms, motor function disorders such as hemiparesis and hemiplegia are most common. Initially, the patient complains that he develops weakness in the left or right limbs (one-sided lesion is typical), often a unilateral disturbance of sensitivity (hemihypesthesia) joins these symptoms.

In the clinical picture of hemorrhagic stroke, there may be a speech disorder (dysarthria or aphasia), the appearance of pathological reflexes, and impaired perception of information (visual or auditory). This pathology is often accompanied by impaired swallowing function (dysphagia). The latter violation is dangerous because aspiration of the contents of the oral cavity into the lungs can lead to the development of severe pneumonia.

hemorrhagic stroke. Diagnostics

The preliminary diagnosis is made on the basis of the anamnesis and clinical picture. The neuropathologist draws attention to such characteristic signs of hemorrhagic stroke as a sudden onset and a sharp throbbing headache at the onset of the disease. Indomitable vomiting and loss of consciousness also indicate the hemorrhagic nature of the stroke.

However, anamnesis data and an objective examination of the patient are not enough for a final diagnosis. For the diagnosis of hemorrhagic stroke, additional examination methods are needed, among which the most informative are computed tomography and magnetic resonance imaging.

On CT or MRI with a diagnosis of extensive hemorrhagic stroke, a focal foreign formation in the brain tissue is visible, which leads to swelling of the brain, an increase in its volume and displacement of brain structures. It should be borne in mind that small hemorrhages are not accompanied by displacements of brain structures, which greatly simplifies therapy and improves prognosis.

However, the differential diagnosis of ischemic stroke and hemorrhagic stroke with such small (up to 2 cm in diameter) foci of hemorrhage is often difficult. Such a hemorrhagic stroke most often debuts with headache and focal symptoms: the patient complains of a throbbing headache, which is joined by gradually increasing weakness in the limbs and decreased sensitivity (one-sided). Facial asymmetry, speech impairment, and oculomotor disorders may occur. The clinical picture largely repeats the clinic of ischemic stroke, and therefore an accurate diagnosis in this case is possible only after additional examination methods.

hemorrhagic stroke. Treatment

Therapy of hemorrhagic stroke in the acute period is aimed at preventing the progression of the disease and combating cerebral edema. Prescribed drugs that lower blood pressure, vascular and hemostatic drugs, analgesics, antispasmodics, diuretics and hypoglycemic drugs (according to indications). Rehabilitation of the patient in the direction of restoring lost functions and regression of deficient symptoms should begin as early as possible.

hemorrhagic stroke. Causes. Symptoms. First aid for stroke

Hemorrhagic stroke- acute violation of cerebral circulation, which is characterized by hemorrhage in the brain tissue with the development of appropriate clinical symptoms.

Hemorrhagic stroke is a much more rare pathology compared to ischemic stroke, their ratio in the incidence structure is approximately 1:4-1:5, however, the development of the hemorrhagic form and the presence of hemorrhage causes a much more severe course of the disease and much more often ends in death.

In hemorrhagic stroke, not just timely, but as early as possible medical care is extremely important, therefore, even when the first symptoms of the disease appear, it is necessary to immediately call an ambulance for an early examination by a doctor and determine further diagnostic and therapeutic tactics.

Causes of hemorrhagic stroke

The causes of hemorrhagic stroke are very diverse, but most often the disease occurs acutely against the background of a critical increase in blood pressure. Too high pressure inside the vessel leads to a rupture of its wall and outflow of blood into the brain tissue. However, it should be understood that the cause is not a single increase in pressure, but long-term arterial hypertension, against which the vascular wall changes, as a result of which it becomes less elastic and more fragile.

In more rare cases, the cause of hemorrhagic stroke is a congenital change in the vascular wall - aneurysms and malformations, as a result of which the vessels are less resistant to the action of various factors, including increased blood pressure.

Factors that can contribute to the development of hemorrhagic stroke are cerebral atherosclerosis, inflammation of the vascular wall, which can be observed in rheumatism, systemic vasculitis and other rheumatological diseases, as well as blood diseases, in particular thrombocytopenia, in which there is increased bleeding and significantly increases the risk of developing hemorrhagic stroke.

Thus, it should be understood that hemorrhagic stroke is not a pathology that develops for no apparent reason. This means that timely examination and treatment, first of all, of arterial hypertension, as well as vascular deformities, can prevent the development of such a serious and life-threatening pathology as hemorrhagic stroke.

Symptoms in the development of hemorrhagic stroke

Unlike ischemic stroke, the clinic of hemorrhagic stroke always develops acutely, sometimes the disease can even mimic an epileptic attack, starting suddenly and accompanied by loss of consciousness and cramps in the limbs.

However, most often hemorrhagic stroke is accompanied by such general cerebral symptoms as a severe headache of a pressing nature in the head or only in the back of the head, pain in the eyeballs, which increases with movement, dizziness and unsteadiness of gait, tinnitus. All these complaints are accompanied by an increase in blood pressure, at the peak of which vomiting may occur, which does not bring relief, nausea is almost permanent.

For hemorrhagic stroke, in contrast to ischemic stroke, loss of consciousness, soporous or coma, as well as pronounced focal disorders are more characteristic, which manifest themselves:

- paresis of the facial nerve (omission of the eyelid, cheek in the form of a sail, omission of the corner of the mouth, smoothed frontal folds),

- paraplegia (impaired movement in the legs or arms),

- hemiplegia (impaired movement in one of the parts of the body),

monoplegia (impaired movement in one of the limbs),

- anisocoria (pupils of different sizes),

- violation of the sensitivity of the skin and muscles, and so on.

If the hemorrhage has occurred in the meninges, then the clinical manifestations may be similar to those of meningitis. There is a severe headache, nausea and vomiting develops, which does not bring relief, and positive meningeal signs are also determined. In general, it should be said that subarachnoid hemorrhage is prognostically more favorable than parenchymal hemorrhage. The hemorrhage in the ventricles of the brain proceeds most unfavorably, in which the lethality exceeds 90%.

Diagnosis of hemorrhagic stroke

The most important thing in diagnosing a hemorrhagic stroke is timely seeking professional medical help. That is why, when the first signs of a hemorrhagic stroke appear, or even just with an increase in pressure, we advise you call an ambulance. Qualified doctors will arrive at the place in a matter of minutes, after examining the patient, a preliminary diagnosis will be made and further tactics of examination and treatment will be determined. Which is extremely important, especially in such formidable diseases as hemorrhagic stroke.

Diagnostic measures for this pathology are reduced to conducting computed tomography, which allows you to identify the focus, determine its nature, size and localization. In the presence of subarachnoid hemorrhage or diagnostic difficulties, a lumbar puncture may be performed for diagnostic purposes.

First aid and therapeutic measures for hemorrhagic stroke

When the first signs of a stroke appear, and we are talking about both cerebral and focal symptoms, you should immediately seek help. At the same time, it is not worth taking any drugs on your own, including drugs that reduce blood pressure, and even more so aspirin, which today is prescribed to almost all patients with coronary heart disease and arterial hypertension.

The fact is that a too rapid decrease in blood pressure during the development of a stroke can only aggravate the course of the disease and increase the area of ​​necrosis. All that needs to be done in the first stages is to lay the patient down and provide access to fresh air. If the patient has lost consciousness and convulsions have begun, then it is necessary to throw back the head to prevent biting the tongue, and lay it on a soft surface in order to prevent injury.

The primary therapeutic measure in most cases is surgery, which allows you to eliminate the focus of hemorrhage and reduce cerebral edema, preventing the cerebellum from wedging into the foramen magnum. Indications for surgical treatment are determined by neurosurgeons after performing computed tomography. Our emergency medical service will help to deliver the patient to the clinic as soon as possible, where appropriate examinations will be performed and a specialist consultation will be held.

If the operation is impossible, then medical treatment is carried out, aimed at eliminating life-threatening complications (cerebral edema) and reducing the area of ​​damage. Such treatment includes the use of diuretics, neuroprotectors, antioxidants, nootropics, metabolic drugs, and blood pressure correctors, which should include a gradual and gentle decrease in blood pressure.

It should be noted that therapeutic measures for hemorrhagic stroke do not always give the desired effect, and the disease itself often ends in disability and has a high mortality rate. And only as early as possible seeking medical help and performing all diagnostic and therapeutic measures as soon as possible from the onset of the development of the disease allows minimizing possible complications and achieving an early and more pronounced recovery of functions.

Please contact our private emergency medical service. be confident in the high qualification of specialists and responsible approach to each patient, which are confirmed by years of our work.

Remember that time is one of the main enemies in the development of such a severe pathology as a hemorrhagic stroke, and it is you who can defeat it in a certain sense by contacting our services when the first signs of the disease appear.

Examples of transportation of patients with hemorrhagic stroke:

— On calling an ambulance resuscitation team to the Vladimir region to a patient with a stroke.