Hemorrhagic stroke
Stroke
is acute disorders of cerebral circulation, rapidly developing clinical signs of focal (at times
global) disturbance of cerebral function, lasting more than 24 hours or leading to death
with no apparent cause other then that of vascular origin
Hemorrhagic stroke
Intracerebral (when the hemorrhage is into the
substance or parenchyma of the brain )
Membrane
subarachnoid (when the bleeding originates in the
subarachnoid spaces surrounding the brain)
epidural and subdural
Combined
subarachnoid parenchymatose
parenchymatose subarachnoid
parenchymatoseventricular
ventricular
The most common causes of hemorrhage
are:
Hypertension
Symptomatic arterial hypertension (at kidney diseases, systemic
vessel processes)
Inborn arterial and arterio venous malformations
Blood diseases (leucosis, polycythemia)
Cerebral atherosclerosis
Intoxications, such as uremia, sepsis
The main periods of stroke
Acute (up to 3 4 months)
Renewal (up to 1 year)
Residual
Stages of acute period
Precursors
Apoplectic stroke
Focal signs
General cerebral symptoms
severe headache
nausea
vomiting
seizures
consciousness disorders
- sopor
- stupor
- semicoma
- coma
Coma
is characterized by deep
consciousness disorder,
disturbance of breathing and
heart activity. The patient
doesnt respond to stimuli.
Coma
response to stimuli is absent
eyes are closed, mouth is opened
face is red, lips are cyanotic, skin is cold,
neck vessels are pulsing
there is breathing disturbance
pulse is strained and slow
blood pressure is increased
temperature increases in 24 hours
patient is lying on his back
all muscles are relaxed
pupils are changed (there can be anizokoria, cross eyes,
sometimes gaze paresis can be observed)
mouth angle is a little bit lower
On the opposite side
hemiplegia is often observed:
the arm is falling down like bine
there is hypotonia of muscles
reflexes are low
Babinski sign is often observed too
Secondary brain stem syndrome
progressive breathing disorders
disturbance of heart activity
consciousness disorders
disturbance of eye movements
changes of muscle tonus (hormetonia)
autonomic disorders (sweating,
tachycardia, hyperthermia)
Brain stem hemorrhage
tetraparesis
alternating syndromes
eye movements disorders
Nystagmus
gorge disorders
cerebellar syndromes.
Pons hemorrhage
ptosis
gaze paresis
increased muscular tone
(hormetonia)
Cerebellar hemorrhage
Dizziness
Severe headache in occipital lobe
Vomiting
Eye movements disorders
Ptosis
Gervig Mazhandi syndrome, Parino syndrome
Cerebellar symptoms - nystagmus, dysartria,
hypotonia, ataxia
Paresis of extremities is not common
Complication of intracerebral hemorrhage
is rupture into the ventricle system. This is usually associated with:
worsening of patients state
Hyperthermia
breathing disorders
hormetonia manifests
as changes of muscle tone in
extremities, when hypotonia is changed into
hypertonia in a few seconds or minutes.
Diagnostics
In blood usually leucocytosis, related lymphopenia,
hyperglycemia (up to 8 10 mmole per liter)
In liquor high pressure during lubar puncture a great
number of erythrocytes are found
On eye fundus retinal hemorrhages, hypertonic
angioretinopathy and Salus symptoms are observed
At echoencephaloscopy there is dislocation of middle
structures on 6 7 sm to the healthy side
At angiography - aneurysm, dislocation of blood
vessels, to find out zone without vessels
CT and MRI find out hyperdensive focuses.
Differential diagnosis
Infarction of brain (thrombembolic)
Epistatus
Uremic coma
Diabetic coma
Traumatic hemorrhage
Brain tumor with inside hemorrhage
Subarachnoid hemorrhage
Aetiologic factors:
Aneurysmatic ( 50 62 % ) aneurysm rupture.
Hypertensive ( at hypertension )
Atherosclerotic ( 15 % )
Traumatic ( 5 6 % )
Infectious toxic ( 8.5 % )
Blastomatose ( at tumors )
Pathohemic ( at blood diseases )
Cryptogenic ( 4 4.8 % )
Clinical features
Severe headache or feeling of hot liquid flowing in
the brain (pain is local in the region of occipital
lobe). Later pains in neck, back appear, sometimes
they irradiate in legs.
Simultaneously with headache vomiting and nausea
occur.
there are other general cerebral symptoms: short
loss of consciousness, psychomotor excitement,
seizures.
Clinical features
Meningeal syndrome
rigidity of occipital muscles
symptoms of Kernig, Brudzinsky
general hyperesthesia.
Significant focal neurologic symptoms are not
common. Only in case of basal hemorrhage CNs
suffer (that is the reason of ptosis, cross eye,
dyplopia, paresis of mimic muscles). Thats why
lesion of CNs is typical for basal aneurysm rupture.
Complications
Brain edema
Recurrent SH
Occlusive hydrocephalia
Brain infarction
Diagnosis
Stroke like development with general cerebral and meningeal
symptoms and absence of significant focal neurologic deficit
The presence of blood in liquor (bleeding liquor during first day and
yellow liquor on 3rd 5th day)
Retinal hemorrhages are on eye fundus
Differential diagnosis
Meningitis
Acute food toxic infection
Infectious diseases
Strokes treatment
Nondifferential treatment includes:
Prevention and treatment of pulmonary
insufficiency
Liquidation of heart vascular disorders
Brain edema treatment
Normalization of water electrolytes balance
and acid alkali balance
Osmosis correction
Improving of brain metabolism
Liquidation of hyperthermia and other
autonomic disorders
Liquidation of heart vascular
disorders
At increased blood pressure we use
Clofelini 1 3 ml 0.01 % solution i/m, i/v.
Dibasoli 3 4 ml 1 % solution i/v
Droperidoli 1 ml 0.25 % solution i/v
Rasedili 1 2 ml 0.1 % i/v, I / m,
- adrenoblockers ( anaprilini, obzidani, inderali )
peripheral vasodilatators ( Natrii nytroprussidi , appresini ) in combination with
euphyllini
At low blood pressure we prescribe
Dexamethazoni 4 8 mg i/v by drops in physiological
solution
Prednizoloni 60 120 mg i/v by drops in physiological
solution
In order to improve heart activity we use strofantini,
corgliconi, cordiamini
Brain edema treatment
Diuretics
Corticosteroids
Albumini
Ganglioblockers
20 % mannit
Manitoli
Glycerini
Lazix
Diakarbi
Differential treatment of hemorrhage
The main directions of treatment are:
To lower increased blood pressure
To liquidate brain edema and lower intracranial pressure
To increase coagulative properties of blood and decrease
penetrance of vessels wall
To prevent and treat cerebral vessels spasm
To normalize vital and autonomic functions and prevent
complications
To treat hypoxia and brain metabolism disorders
