Hemorrhagic stroke

Hemorrhagic stroke is a type of stroke that occurs when an artery inside the brain ruptures, causing bleeding into the brain tissue. However, the term "hemorrhagic stroke" is generally used in clinical practice to refer to intracerebral hemorrhage caused by the most common cerebrovascular diseases: hypertension, atherosclerosis, and amyloid angiopathy.

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Epidemiology

Hemorrhagic stroke accounts for 8-15% of all strokes.

The polyetiology of hemorrhagic stroke determines the possibility of its development at any age, including childhood, however, if we take into account the most common etiological factors, cerebral hemorrhage is most often experienced at the age of 50-70 years.

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Causes hemorrhagic stroke

The cause of a hemorrhagic stroke is the release of blood beyond the vascular bed into the brain substance, ventricles or under the membranes of the brain. Hemorrhagic strokes account for up to 15% of all cerebrovascular accidents.

The cause may be various diseases and pathological conditions: arterial hypertension of various genesis, amyloid angiopathy, aneurysms and vascular malformations of the central nervous system, blood diseases (erythremia, thrombophilia), vasculitis, systemic diseases of connective tissue. Hemorrhages may occur during treatment with anticoagulants and fibrinolytic agents, as well as with abuse of other drugs (for example, amphetamine, cocaine).

The most common causes are hypertension and amyloid angiopathy.

The causes of hemorrhagic stroke are as follows:

• In 60-70% of patients the cause is arterial hypertension.
• In 20% of cases - arterial aneurysm or arteriovenous malformation.
• Approximately 8-10% are various vascular lesions due to atherosclerosis.
• Spontaneous hemorrhage into the subarachnoid space in 70-80% of cases is caused by ruptures of arterial aneurysms (AA), in 5-10% - arteriovenous malformations (AVM).
• Disorders of the blood coagulation system and the use of anticoagulants are very rare causes of subarachnoid hemorrhage (SAH).
• In 15% of cases, the source of bleeding remains unknown.

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Pathogenesis

The pathogenesis of hemorrhagic stroke is associated with the rupture of an artery inside the brain and bleeding into the brain tissue. This can occur due to several main mechanisms:

1. Aneurysms: Aneurysms are knot-shaped dilations of arteries inside the brain. As the aneurysm grows, the artery walls become thinner and less stable. When the aneurysm ruptures, it causes blood to leak into the brain tissue.
2. Arteriovenous malformations (AVMs): AVMs are abnormal connections between arteries and veins in the brain. AVMs have an unusual structure that may be weaker than normal arteries and veins. When an AVM ruptures, it causes bleeding into the brain.
3. Hypertension (high blood pressure): High blood pressure can weaken the walls of arteries in the brain, making them more susceptible to rupture.
4. Trauma: Head trauma can damage arteries or veins in the brain, which can cause bleeding.

Symptoms hemorrhagic stroke

The clinical picture of intracerebral hemorrhage is quite typical. Hemorrhagic stroke has an acute sudden onset, often against the background of high blood pressure. Characteristic are severe headache, dizziness, nausea and vomiting, rapid development of focal symptoms, followed by a progressive decrease in the level of wakefulness - from moderate stupor to a comatose state. Depression of consciousness may be preceded by a short period of psychomotor agitation. Subcortical hemorrhages may begin with an epileptiform seizure.

Focal neurological symptoms of hemorrhagic stroke depend on the location of the hematoma. Typical focal symptoms, taking into account the most common localization of intracerebral hematomas, are hemiparesis, speech and sensitivity disorders, frontal symptoms in the form of memory impairment, criticism, behavior.

The severity of the patient's condition immediately after the hemorrhage and in the following days depends primarily on the severity of general cerebral and dislocation symptoms, which in turn are determined by the volume of the intracerebral hematoma and its localization. In the case of extensive hemorrhages and hemorrhages of deep localization, secondary brainstem symptoms caused by the dislocation of the brain quickly appear in the clinical picture. Hemorrhages in the brainstem and extensive cerebellar hematomas are characterized by a rapid impairment of consciousness and vital functions. Hemorrhages with a breakthrough into the ventricular system are the most severe. They are characterized by the appearance of hormetic seizures, hyperthermia, meningeal symptoms, rapid depression of consciousness, and the development of brainstem symptoms.

The severity of focal symptoms in parenchymatous hemorrhages depends mainly on the localization of the hematoma. Small hematomas in the area of the internal capsule can lead to a much more severe focal syndrome than larger hematomas located in functionally less significant parts of the brain.

Course of hemorrhagic stroke

The most severe period of hemorrhage, especially with extensive hematomas, is the first 2-3 weeks of the disease. The severity of the patient's condition at this stage is due to both the hematoma itself and the increasing cerebral edema in the first days of the disease, which is manifested in the development and progression of general cerebral and dislocation symptoms. Edema and dislocation of the brain become the main cause of death of patients in the acute period of the disease. The addition or decompensation of previously existing somatic complications (pneumonia, liver and kidney dysfunction, diabetes mellitus, etc.) are also typical for this period. Due to the patient's immobility, pulmonary embolism is a great danger at this stage of the disease. By the end of the 2-3rd week of the disease, general cerebral symptoms begin to regress in surviving patients, and the consequences of focal brain damage come to the fore, subsequently determining the degree of the patient's disability.

Forms

Intracranial hemorrhages, depending on the location of the spilled blood, are divided into intracerebral (parenchymatous), subarachnoid, ventricular and mixed (parenchymatous-ventricular, subarachnoid-parenchymatous, subarachnoid-parenchymatous-ventricular, etc.). The type of hemorrhage largely depends on the etiologic factor.

Intracerebral hematomas

ICD-10 codes

I61.0-I61.9. Intracerebral hemorrhage.

In addition to etiology, intracerebral hematomas are subdivided by location and volume. In the vast majority of cases (up to 90%), hematomas are localized in the supratentorial parts of the brain. Lobar, lateral, medial and mixed intracerebral hematomas are distinguished.

• Lobar hemorrhages are those in which the blood does not go beyond the cortex and white matter of the corresponding lobe or lobes of the brain.
• Hemorrhages into the subcortical nuclei (outside the internal capsule) are usually referred to as lateral strokes, and hemorrhages into the thalamus are referred to as medial strokes (inside the internal capsule).
• In practice, mixed intracerebral hematomas are most often encountered, when blood spreads within several anatomical structures.

Hematomas of the posterior cranial fossa account for about 10% of all intracerebral hematomas. Most often they are located in the cerebellum, less often in the brainstem, where their "favorite" localization is the pons.

Hemorrhages in the medial parts of the cerebral hemispheres, as well as hematomas of the posterior cranial fossa, are accompanied by a breakthrough of blood into the ventricular system in approximately 30% of cases.

The volume of intracerebral hematomas in hemorrhagic stroke can vary widely - from a few milliliters to 100 ml or more. There are various ways to determine the volume of a hematoma. The simplest of them is to calculate the volume based on CT data using the following formula: maximum height x maximum length x maximum width: 2. The distribution of hematomas by volume is very arbitrary. It is customary to divide hematomas into small (up to 20 ml), medium (20-50 ml) and large (>50 ml). Small, medium and large hematomas occur with approximately the same frequency.

Hemorrhagic stroke can take several forms, including the following:

1. Intracerebral hemorrhage (ICH): This is the most common form of hemorrhagic stroke. ICH occurs when an artery inside the brain ruptures, causing blood to leak into the surrounding brain tissue. This can cause damage to the brain tissue in the area of the hemorrhage.
2. Subarachnoid hemorrhage (SAH): SAH occurs when blood leaks into the space between the surface of the brain and its inner lining, called the arachnoid membrane. It is most often caused by a ruptured aneurysm, but can also be due to other causes. SAH is usually accompanied by severe headache and can cause seizures.
3. Subdural hemorrhage: This form of hemorrhagic stroke is characterized by bleeding under the dura mater, which is the membrane between the brain and the inside of the skull. It is often associated with head trauma and may have a slow onset of symptoms.
4. Epidural Hemorrhage: An epidural hemorrhage occurs when blood collects between the skull and the dura mater. It is also associated with trauma and can lead to compression of brain structures, requiring emergency surgery.

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Complications and consequences

Hemorrhagic stroke can have serious complications and consequences. Some of these include:

1. Impaired brain function: A hemorrhagic stroke causes damage to the brain tissue in the area of the hemorrhage. This can cause impairment of motor function, sensory function, coordination, and speech skills.
2. Seizures: In some cases, hemorrhagic stroke can cause seizures (epileptic seizures), which further worsens the patient's condition.
3. Paralysis: A brain hemorrhage can result in paralysis of half the body (hemiparesis) or one side of the body (hemiplegia), depending on which part of the brain is damaged.
4. Loss of consciousness: Hemorrhagic stroke can cause loss of consciousness and coma, which may require ventilator support and intensive care.
5. Infections: After a stroke, especially if the patient is in the hospital or undergoing long-term rehabilitation, infections such as pneumonia or urinary tract infections may develop.
6. Cardiac complications: Hemorrhagic stroke can affect the heart and lead to cardiac arrhythmias, low blood pressure, and other cardiac complications.
7. Long-term disabling consequences: Many patients who survive a hemorrhagic stroke experience long-term consequences such as loss of ability to care for themselves, disability, and decreased quality of life.
8. Recurrences: People who have had a hemorrhagic stroke may be at risk of having more strokes, especially if they do not take steps to control risk factors such as hypertension or atherosclerosis.

Diagnostics hemorrhagic stroke

Diagnosis of hemorrhagic stroke involves a number of methods and procedures aimed at determining the presence of a stroke, determining its type, and assessing the extent of damage. It is important to note that rapid and accurate diagnosis of hemorrhagic stroke is critical to choosing the appropriate treatment. The main methods of diagnosing hemorrhagic stroke are listed below:

1. Clinical examination: The doctor begins by examining the patient and assessing his symptoms. Characteristic signs of a hemorrhagic stroke may include severe headache, vomiting, seizures, decreased level of consciousness, and symptoms associated with high blood pressure and heart problems.
2. Educational studies: The following educational studies may be performed to visualize the brain and detect hemorrhages:

• Computed tomography (CT) scan of the head: Allows to detect the presence of hemorrhage and determine its location.
• Magnetic resonance imaging (MRI) of the head: Provides more detailed images of the brain and bleeding.

The main diagnostic method for acute cerebrovascular accident is CT or MRI. These methods allow to differentiate the type of stroke, determine the location and volume of intracerebral hematoma, the degree of concomitant edema and dislocation of the brain, the presence and prevalence of ventricular hemorrhage. The study should be performed as early as possible, since its results largely determine the tactics of patient management and treatment. Repeated CT studies are also necessary to track the evolution of the hematoma and the state of the brain tissue in dynamics. The latter is especially important for the timely correction of drug therapy. Evaluation of CT data, as a rule, does not present difficulties regardless of the time elapsed since the onset of the disease. Interpretation of MRI data seems more complex, which is due to the change in the MP signal depending on the evolution of the hematoma. The most common erroneous diagnosis is "intracerebral tumor with hemorrhage."

• Digital angiography: A test that uses a radiopaque substance to visualize blood vessels in the brain and identify the source of bleeding.

3. Blood test: This is done to measure platelet levels, coagulation status, and other parameters that may be associated with hemorrhagic stroke.
4. Lumbar puncture (spinal tap): In some cases, this may be needed to rule out other possible causes of symptoms.
5. Electrocardiography (ECG): A test of cardiac activity to evaluate heart function and detect arrhythmias.
6. Additional tests: Other additional tests may include echocardiography (ultrasound of the heart), which can be useful in identifying sources of emboli (blood clots) causing hemorrhagic stroke.

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Differential diagnosis

Hemorrhagic stroke should be differentiated primarily from ischemic stroke, which accounts for up to 80-85% of all strokes. It is necessary to establish an accurate diagnosis in order to begin appropriate therapy as early as possible. Differential diagnostics based on clinical data is not always possible, so it is preferable to hospitalize patients diagnosed with stroke in hospitals equipped with CT or MRI equipment.

Ischemic stroke is characterized by a slower increase in general cerebral symptoms, the absence of meningeal symptoms, and in some cases the presence of precursors in the form of transient cerebrovascular accidents, and a history of cardiac arrhythmia. The cerebrospinal fluid taken by lumbar puncture has a normal composition in ischemic stroke, but may contain blood in hemorrhagic stroke. It should be emphasized that if the patient is in a generally serious condition, it is better not to perform a lumbar puncture or to perform it with great caution, since the removal of cerebrospinal fluid may cause brain dislocation.

Intracerebral hematomas of hypertensive genesis must also be differentiated from hematomas of other etiologies, as well as from hemorrhages into the ischemic focus or tumor. The history of the disease, the patient's age, and the localization of the hematoma in the brain matter are of great importance.

In case of hemorrhage from an aneurysm, hematomas have a typical localization - the mediobasal parts of the frontal lobe in case of aneurysms of the anterior cerebral/anterior communicating artery and the basal parts of the frontal and temporal lobes adjacent to the Sylvian fissure in case of aneurysms of the internal carotid or middle cerebral artery. MRI can also show the aneurysm itself or pathological vessels of the arteriovenous malformation.

If a ruptured aneurysm or arteriovenous malformation is suspected, which may primarily be indicated by the patient's young age, an angiographic examination is necessary.

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Treatment hemorrhagic stroke

Treatment of patients with intracerebral hematoma can be conservative and surgical.

The question of treatment tactics must be decided on the basis of the results of a comprehensive clinical and instrumental assessment of the patient and mandatory consultation with a neurosurgeon.

Drug treatment of hemorrhagic stroke

The principles of conservative treatment of patients with intracerebral hematomas correspond to the general principles of treatment of patients with any type of stroke. Measures for treating a patient with suspected intracerebral hematoma should be started at the pre-hospital stage, where the adequacy of external respiration and cardiovascular activity should be assessed first. Intubation with the connection of artificial ventilation is necessary if signs of respiratory failure are present. Normalization of arterial pressure is of the greatest importance in the correction of the state of the cardiovascular system: as a rule, it is sharply elevated in patients with hemorrhagic stroke.

In hospital, measures should be continued to ensure adequate external respiration and blood oxygenation, normalize the functions of the cardiovascular system, and maintain water-electrolyte balance. The most important measure is therapy aimed at reducing cerebral edema. The use of hemostatic drugs and drugs that reduce the permeability of the vascular wall is recommended. Prevention of thromboembolism is necessary. Careful care of the patient is of great importance.

When correcting arterial pressure, its sharp and significant decrease should be avoided, as this can lead to a decrease in perfusion pressure, especially in conditions of intracranial hypertension. It is recommended to maintain the mean arterial pressure at a level of 130 mm Hg. To reduce intracranial pressure, osmodiuretics are used in combination with saluretics, provided that blood electrolytes are monitored at least 2 times a day, barbiturates, intravenous administration of colloidal solutions. The use of glucocorticoids is ineffective. Drug therapy must be carried out under conditions of monitoring the main indicators characterizing the state of the cerebrovascular system and vital functions. The scope of monitoring depends on the severity of the patient.

When treating a patient with an intracerebral hematoma, it is necessary to take into account that hypertension leads to damage not only to the vascular system of the brain, but also to other organs and systems. Patients with hypertension often have various concomitant diseases (diabetes mellitus, atherosclerosis, obesity), therefore, patients with an intracerebral hematoma are characterized by the rapid addition of various somatic complications.

Surgical treatment of hemorrhagic stroke

The decision on the indications for surgical intervention for intracerebral hematoma depends on many factors, the most important of which are the volume, localization of the spilled blood and the patient's condition. Despite numerous studies on the advisability of surgical treatment of intracerebral hematomas, there is no consensus on this issue. Randomized studies have failed to prove the advantages of one method or another. Non-randomized studies indicate the effectiveness of surgery under certain conditions and in certain groups of patients.

When justifying an operation, the main goal is to save the patient's life, so most interventions are performed in the immediate aftermath of the hemorrhage. In some cases, hematomas can be removed in order to more effectively eliminate focal neurological disorders. Such operations can be delayed.

A comparative analysis of the results of conservative and surgical treatment showed that in case of supratentorial hematomas up to 30 ml in volume, surgical treatment is inappropriate regardless of the location of the hematoma, since small hematomas rarely cause vital disorders. In case of hematomas over 60 ml in volume, the outcome is generally worse with conservative treatment. In patients with medium-volume hematomas (30-60 ml), it is most difficult to determine the indications for surgery and choose the method of surgical intervention. In these cases, the degree of impaired consciousness, the severity of dislocation symptoms, the localization of the hematoma, the severity of perifocal cerebral edema, and the presence of concomitant ventricular hemorrhage are prognostically significant. A comatose state, especially with a pronounced impairment of stem functions, is considered a contraindication to surgery, since the mortality rate reaches 100% when attempting to operate on such patients. The localization of hematomas in deep structures is unfavorable.

In case of cerebellar hematomas, the indications for surgery are broader, since hematomas in this location can lead to rapid disruption of vital functions.

Thus, surgical interventions aimed at removing intracerebral hematoma are indicated primarily for patients with lobar or lateral hematomas with a volume of more than 50 ml, as well as for patients with cerebellar hematomas.

The choice of the surgical method depends primarily on the location and size of the hematoma. Lobar and lateral hematomas are best removed directly. In recent years, the puncture-aspiration method with local fibrinolysis has also been widely used. In medial and mixed strokes, stereotactic removal of hematomas is considered more gentle. However, with stereotactic removal, bleeding relapses occur more often, since careful hemostasis cannot be performed during the operation.

In addition to hematoma removal, ventricular drainage may be necessary in hemorrhagic stroke. External ventricular drainage is indicated in cases of massive ventricular hemorrhage, occlusive hydrops in patients with cerebellar hematomas, and to control intracranial pressure.

Prevention

Unfavorable outcomes of hemorrhagic stroke once again emphasize the importance of disease prevention. The main measures in this direction are to identify as early as possible and conduct systematic adequate drug treatment of patients suffering from hypertension, which allows to reduce the risk of stroke by 40-50%, as well as to eliminate risk factors for hypertension and stroke: smoking, drinking large doses of alcohol, diabetes, hypercholesterolemia.

Forecast

The prognosis for hemorrhagic stroke is generally unfavorable. The overall mortality rate reaches 60-70%, after removal of intracerebral hematomas - about 50%. The main causes of death in both operated and non-operated patients are increasing edema and dislocation of the brain (30-40%). The second most common cause is recurrent hemorrhage (10-20%). About 2/3 of patients who have suffered a stroke remain disabled. The main factors determining the outcome of the disease are considered to be the volume of the hematoma, concomitant breakthrough of blood into the ventricles, localization of the hematoma in the brainstem, previous use of anticoagulants, previous heart disease, old age.

List of well-known neurology textbooks that may be useful:

1. "Adams and Victor's Principles of Neurology" by Morton S. Dight, Martin Samuel, Allan H. Roper.
2. "Bradley and Daroff's Neurology in Clinical Practice" by Robert B. Daroff, Joseph J. Fencheau, Joseph B. Jang, Richard B. Rosenblum.
3. "Harrison's Principles of Internal Medicine" by Dennis L. Kasper, Anthony S. Fauci, Joseph Loscalzo, et al. (an extensive textbook on internal medicine, including sections on neurology).
4. "Neurology: National Medical Series for Independent Study" by Morton D. Dight.
5. "Neurology for the Non-Neurologist" by Walter R. Billings.
6. "Principles of Neurology" by Raymond D. Adams, Maurice V. Victor.
7. "Neurology: A Queen Square Textbook" by Garrett Fitzgerald, Michael P. Bleasdale, Rob Phillips, and others.

References

Gusev, E. I. Neurology: national leadership: in 2 volumes / ed. E. I. Guseva, A. N. Konovalova, V. I. Skvortsova. - 2nd ed., revised. and additional - Moscow: GEOTAR-Media, 2021