Download Hemorrhagic stroke

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
parenchymatose–ventricular
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
Aneurysm
Aneurysm
According to the localization there are :
Lateral hemorrhage (they are located laterally
compared with the internal capsule)
Medial hemorrhage (they are located
medially compared with the internal capsule)
Combined hemorrhages (they take the
whole region of basal nuclei: subcortical nuclei, thalamus,
internal capsule)
Brain stem hemorrhages
Cerebellar hemorrhages
In hemisphere
In ventricules
Pathomorphology
Per rexis
Per diapedesis
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 doesn’t 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
Large hemisphere hemorrhage
meningeal signs
vomiting and dysphagia
retention of urine or involuntary
urination
in case of cortex irritation epileptic
attacks
Sign of paralysis in right side
Sign of central paralysis
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 patient’s 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.
In liquor high pressure during lubar puncture a
great number of erythrocytes are found
1. normal
2. subarachnoid
hemorrhage
3. intracerebral
hemorrhage
4. xantochromia
On eye fundus – retinal hemorrhages,
hypertonic angioretinopathy and Salus symptoms are
observed
1-2 embolism of
retinal vessels
3 – hypertensive
encephalopathy
4 – subarachnoid
hemorrhage
At echoencephaloscopy
there is dislocation of
middle structures on 6
–7 sm to the healthy
side
Differential diagnosis
Infarction of brain (thrombembolic)
Epistatus
Uremic coma
Diabetic coma
Traumatic hemorrhage
Brain tumor with inside hemorrhage
Subdural haematoma
Subdural haematoma
MRI. Intracerebral hemorrhig
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.
Subarachnoid hemorrhig
Subarachnoid hemorrhig
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). That’s why
lesion of CNs is typical for basal aneurysm
rupture.
Kernig’s sign
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