What is a hemorrhagic stroke of the brain consequences. Hemorrhagic stroke - symptoms, consequences of damage to the right and left sides of the brain. Undifferentiated stroke treatment includes

Unfortunately, today hemorrhagic stroke in Russia is the second most common. Moreover, not only elderly men and women can suffer, but also children in adolescence, and very small ones, babies. Timely provided pre-medical and medical care improves the prognosis for the patient by 15%.

What is a hemorrhagic stroke?

A hemorrhagic stroke is an intracerebral hemorrhage that occurs due to a rupture of the wall of an artery or vein. In this case, brain cells in a certain part of it suffer significantly. The brain receives less oxygen and important elements.

Neurons begin to die urgently after 20 minutes from the onset of the attack. In addition, the blood poured into the brain tissue additionally forms a hematoma, which compresses its areas. The patient also develops, which, due to the closedness of the cranium, threatens the patient with dangerous complications in the form of disorders and failure of basic, vital functions. Up to the point that the patient can fall into a lethal coma. The doctors themselves call it that because most patients do not get out of it.

The ICD disease code is I61–I61.9. The range includes all possible types of hemorrhages, depending on their classification according to the area of ​​localization.

Important: at risk are people from the 55+ age group suffering from hypertension, hypertension and atherosclerosis.

Types of stroke

All intracerebral hemorrhages in modern medicine are divided into two main types:

• Hemorrhagic stroke. Indicates the impregnation or infiltration of tissues (parenchyma) with shed blood. Parenchymal tissues die.
• Subarachnoid stroke. Here, blood is poured into the relatively free space between the meninges and the arachnoid. This space is normally filled with CSF (cerebrospinal fluid). Children and from 25 to 40 years are most often affected. Causes are traumatic brain injury or aneurysm rupture. With TBI, the patient develops a subdural intracranial hematoma, which requires surgical intervention.

In turn, hemorrhagic stroke is additionally divided into types, depending on the area in which the hemorrhage can be localized:

1. Putamenal (lateral) bleeding. Localized on the side of the internal capsule. It is the most common of all types of hemorrhages and occurs in almost half of the cases.
2. Subcortical hemorrhage. Localized in the subcortical region. Most often occurs against the background of hypertension.
3. Thalamic. Hematomas and hemorrhages are located closer to the center of the internal capsule.
4. Along with subcortical hemorrhage, these hemorrhages take the second place in frequency.
5. . The area of ​​the cerebellum suffers. Men who are addicted to nicotine are more susceptible to this type of stroke. Cerebellar damage is extremely dangerous and intractable.
6. subdural bleeding. Very similar to subarachnoid, when blood is poured into the space between the two membranes. But here everything happens because of a rupture of a benign tumor in the brain.
7. Stem. Hemorrhage in the brain stem, which in almost 98% of cases entails either the death of the patient, or his almost complete paralysis and further.
8. Cortical. Bleeding occurs in the cerebral cortex. Lobar. The first lobe of the brain suffers.
9. Ventricular (ventricular). Blood is poured into the ventricles of the brain. One of the most dangerous conditions for the patient. IVH (intraventricular hemorrhage) can occur not only in adults, but also in a newborn baby. With such a hemorrhage, a patient of any age almost immediately falls into a coma. Hemorrhagic stroke with a breakthrough into the ventricles occurs in almost 30% of cases.
10. Mixed. Several parts of the brain are affected, and the stroke is called extensive.

Symptoms and causes of hemorrhagic stroke in people of different ages

In general, the clinical picture in all patients with hemorrhagic stroke is approximately the same. Only the causes of rupture of the walls of the artery differ. So, the symptoms and signs of pathology by which hemorrhage can be determined are as follows:

• sudden headache, which the patients themselves then characterize as a blow to the head.
• nausea reflex and single vomiting.
• slowing or quickening of the heart rate.
• breathing failures. Breathing becomes intermittent, frequent.
• the skin is sweaty and cold to the touch.
• paresis of the muscles of the face (skew).
• painful reaction to light and sound.
• if the patient is conscious, one can observe how one of his eyes (the one located on the side of the affected hemisphere) has a pathologically dilated pupil. The patient's gaze is directed towards the area of ​​brain damage, and the eyelid of the eye, located opposite the affected half of the brain, is relaxed.
• the patient's foot on the side of the affected part of the brain is turned outward.

At the same time, for all groups of patients with all types of hemorrhagic strokes, the following symptoms are characteristic:

1. Sudden development of a stroke. More often occurs in the afternoon with high physical exertion or hypertension, in contrast to, which can happen at any time of the day or night.
2. Almost always there is a loss of consciousness.

Important: sometimes the patient can notice such as slight, increased sweating and redness of the face.

In children at any age (including premature ones), a hemorrhagic stroke looks like this:

• Frequent whining and crying (in infants).
• in one-year-old children and older children (feeding is difficult).
• Hemiparesis (muscle weakness on one side of the body).
• Loss of coordination and frequent falls.
• Tension of the occipital and dorsal muscles.

As for the causes of the development of hemorrhage, depending on the age of the patient, these may be such provoking factors:

1. Infants and young children. (chronic vascular inflammation), blood diseases associated with clotting disorders.
2. Teenagers. Smoking, taking toxic substances, injuries, falls and bruises, physical overstrain, chronic vascular and blood diseases, heart failure, the presence of a valve prosthesis.
3. Young people aged 30-45 years. Atherosclerosis, smoking and alcoholism, TBI, aortic aneurysm, frequent stress and overexertion, the presence of chronic diseases of the blood and blood vessels / heart.
4. Elderly patients. Hypertension and obesity, varicose veins and atherosclerosis, vasculitis, blood and cardiovascular diseases, diabetes mellitus, addiction to alcohol, the presence of an electrical pacemaker and other heart prostheses.

Important: in previously pregnant and women who have already given birth, hemorrhage occurs a few days after childbirth. The cause of the pathology is strong straining, large blood loss during childbirth and subsequent failure of the cardiovascular system. The frequency of such cases is 30%. The age of the patients is 35–40 years.

Diagnostics

Before the arrival of the ambulance, the patient can conduct a special test to determine the performance of the muscles of the face, hands and the state of speech. With a stroke, they are severely disturbed. Upon admission of the patient to the hospital, the doctor conducts an initial examination. With the help of characteristic features, it makes only a presumptive diagnosis.

An accurate diagnosis is made based on the results of a full-fledged urgent examination, since the signs of the pathology are also similar to other neurological diseases. In this case, it is necessary to conduct a differential topical diagnosis. To this end, if a cerebral hemorrhage is suspected, a number of measures are taken:

• CT and MRI of the brain. Magnetic resonance imaging allows you to see the entire brain of the patient in a three-dimensional image and determine the area of ​​localization of the head hemorrhage.
• Vascular angiography. Allows you to diagnose the localization of a vessel rupture using a radiopaque substance.

In addition, an additional diagnosis of the patient's body is carried out, in case it is decided to apply an operation to save him. The fact is that surgical interventions on the brain are contraindicated in some cases.

Important: in any case, the patient during the entire period of stay in the hospital is subjected to re-examination to monitor the dynamics of the stroke. Especially in the acute period.

Treatment

Treatment of a patient in a hospital should be comprehensive. At the same time, it is important to understand that the provision of timely emergency prehospital care and the rapid delivery of the patient to the hospital significantly reduce the risk of developing severe complications. In general, the treatment tactics are as follows:

1. Stopping bleeding with the help of special vasoconstrictors, including if the patient also has diapedetic bleeding, in which blood is ejected in jerks.
2. Neutralization of cerebral edema with the help of artificial ventilation of the lungs, the introduction of corticosteroids and diuretics.

Important: in order to prevent a re-strike, it is necessary to keep the patient in a horizontal position with the head and shoulders raised by 30 degrees.

• Correction of blood pressure in order to restore the functioning of the cardiovascular system.
• Control over the level of glucose in the blood and its correction.
• Maintaining normal water and electrolyte balance in the body.
• Feeding the patient, if necessary, through a special nasogastric tube, with which even a bedridden patient can eat.
• Symptomatic treatment aimed at restoring all lost functions.

Medical therapy

To improve the patient's condition, the following substances are used as conservative therapy:

1. Neuroprotectors. Improve blood supply to the brain and prevent the death of living neurons. Often use "Actovegin".
2. Antihypertensive drugs to normalize blood pressure. However, they are administered very carefully so as not to provoke sharp. As a result of such an error, a decrease in cerebral and intracerebral pressure may occur. Apply "Lasix" or "Mannitol".
3. Vasoconstrictive drugs and diuretics to reduce cerebral edema.
4. Nootropic drugs that protect neurons. They use "Cytohorm" and "Somazin". "Cortexin" and "Cytomac", "Cerebrolysin", etc.
5. Antioxidants. Restore tissue cells and protect them from the effects of free radicals.
6. Drugs that increase blood clotting, as a therapeutic and prophylactic agent.
7. Antibiotics in case of bacterial infection.
8. Vasoactive drugs to improve cerebral circulation. It can be "Agapurin", "Sermion", etc.

Surgical intervention

Surgery for hemorrhagic stroke is especially indicated in such cases:

• Subarachnoid hemorrhagic stroke.
• Hemorrhage in the cerebellum.
• Lateral and lobar hemorrhages of medium and large volume.
• Deterioration of the patient's condition.

Inoperable are patients older than 70 years, patients in a coma, patients with a history of stroke or heart attack in the past six months. Also do not perform operations on patients with medial hematoma. All operations are carried out only in the Department of Neurosurgery, subject to the availability of experienced professionals and the necessary equipment.

In relation to the operated patient, three methods of intervention are used:

1. Trepanation. It involves opening the skull and brain tissue to remove the hematoma. The operation is extremely complex and lengthy (5-15 hours). Recovery and recovery after it is not easy and long. The risk of serious complications is high.
2. Puncture. A hole is made in the patient's skull and a hematoma is removed through it by puncture.
3. Drainage. A drainage system is installed in the hole in the cranium and fibrinolytics are injected through it, which dissolve the hematoma. Then all the contents are sucked off through the drain.

Folk methods

Treatments are used already at home with the consent of the doctor to help the patient recover faster after a stroke. The consent of the doctor is required, since even the simplest home remedies can seriously harm the patient. The most commonly used home remedies are:

• Rubbing from vegetable oil and alcohol in a ratio of 2: 1. Apply during the period. Apply to the skin with light stroking movements. After the massage, you can do passive gymnastic exercises for recovery. motor activity joints.
• Wormwood. Use fresh grass juice, mixed in equal parts with honey. Per day, no more than 12 ml of juice, divided into two doses.
• Cinnamon rosehip. Use a decoction of the roots for baths. Baths are carried out every other day for 30-60 days.
• Black elderberry (berries). Brewed and drunk like tea.

In addition to the above folk remedies the patient is shown a special diet high in plant foods and lean meats/fish in the diet. Food should be moderately warm, but not hot. In addition, it is necessary to conduct special classes to restore the mental and emotional state of the patient.

The pathogenesis of the development, treatment and further recovery of the patient implies his rehabilitation for at least three weeks.

Forecast

The prognosis for hemorrhage is quite unpredictable. In general, it all depends on the area of ​​localization of the hemorrhage and its vastness. In addition, the age of the patient and the presence of chronic diseases should be taken into account. According to WHO, approximately 25-30% of patients die in the first month after a stroke. About 50% of patients who survived hemorrhage die within a year after the attack. Approximately 60% of surviving patients remain disabled in one way or another with serious functional disorders.

Doctors say that the rehabilitation period takes from several months to several years. The forecast of almost complete recovery after hemorrhagic stroke is given only for 15-20% of patients, and then against the background of a long recovery period, the algorithm of actions in which is built with the help of the attending physician.

Prevention

In order to prevent cerebral hemorrhage, it is necessary to constantly monitor your health, conduct healthy lifestyle life and be in a normal emotional state. Control over blood pressure, glucose levels and the state of blood vessels will avoid a terrible diagnosis.

Remember, cerebral hemorrhage is a pathology, often incompatible with life. Therefore, the timeliness and literacy of treatment are the main trump cards in the hands of relatives and friends in saving the patient.

They are diagnosed in 7-8% of patients with neuropathology. The disease is characterized by severe pathogenesis with mortality up to 50% and disability up to 80%.

Timely detection of the first signs of the disease and Fast shipping patient to the clinic by about 15% increases the likelihood of a favorable outcome of hemorrhagic stroke.

What is a hemorrhagic stroke?

The nosological form includes two terms: "hemorrhage" is a hemorrhage, and the word "stroke" means infarction (ischemic necrosis) of a part of the brain.

Hemorrhagic stroke is a hypertensive hemorrhage in the parenchyma of the brain, accompanied by an acute violation of cerebral circulation, loss of the functions of the affected area, the development of pathogenesis in the nucleus and the perifocal (around the nucleus) zone. The disease is manifested by general and local neurological symptoms.

Hemorrhagic stroke is mainly a complication of hypertension.

A more severe pathogenesis compared to ischemic stroke is associated with a cumulative effect from:

Hemorrhages in the brain tissue, compression of the surrounding vessels;

Inflammatory-necrotic processes in the core of the stroke;

Dystrophic and inflammatory processes on the periphery of the nucleus.

There are two main types of cerebral hemorrhages of different origin:

Hemorrhagic stroke (HI) - hemorrhage / impregnation of the brain parenchyma;

Subarachnoid hemorrhages (SAH) are non-traumatic hemorrhages in the cerebral cortex, not associated with vascular malformations.

During the initial observation of a patient, hemorrhage is diagnosed as an intracerebral hematoma (ICH). Differentiation is carried out in the clinic based on the results of instrumental (MRI, CT) visualization of the structures of the brain and cranium.

There are several options for localization of hemorrhages in the brain, namely:

Putamenal lateral (lateral) - on the side of the internal capsule;

Subcortical (subcortical);

Lobar - in the first lobe of the brain;

Thalamic (medial) - located to the center of the internal capsule;

mixed;

Cerebellar;

Stem (bridge).

Putamenal strokes are widespread - they account for up to half of all types of hemorrhagic strokes, subcortical and thalamic strokes are less common - about 15% for each type. Hemorrhages in the cerebellum and brain stem are detected much less frequently - up to 8% of all strokes.

The most severe lesions of the body are massive hemorrhages in the hemisphere, trunk or cerebellum of the brain. Hemorrhagic strokes often develop in men who are prone to and have bad habits. The likelihood of cerebral hemorrhage increases with age.

In women aged 30-40 years, the risk of hemorrhagic stroke is associated with childbirth and the postpartum period and is due to the layering of massive labor / postpartum hemorrhage on disorders in the cardiovascular system.

Symptoms of a hemorrhagic stroke

More than a hundred different clinical symptoms of hemorrhagic stroke are known, and the transformation of ischemic stroke into hemorrhagic is also possible. This greatly complicates the differential diagnosis of the disease. The primary signs indicating a stroke should be determined by describing the patient's sensations, changes in speech, strong, impaired consciousness.

Possible precursors of hemorrhagic stroke

Tingling, numbness of half of the face;

Severe sharp pain in the eyes, partial loss of vision;

sudden loss of balance;

Difficulties in understanding speech.

They appear shortly before the attack, but are not mandatory signs of GI.

For hemorrhagic stroke, a sudden onset of the disease is more characteristic. On the eve or immediately before an attack, stress in the form of physical and / or emotional stress is possible.

During a telephone conversation with the operator, it is necessary to clearly describe the signs of a stroke found in the patient.

Signs of a hemorrhagic stroke in a conscious person:

Rapidly increasing headache;

Cardiopalmus;

Intolerance to bright light, "" circles "" and "" midges "" before the eyes;

Difficult speech.

Signs of hemorrhagic stroke in an unconscious person:

Do not try to bring the patient back to consciousness!

There are four distinct stages in the regression of consciousness. They can be defined as follows:

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.

An epileptiform (similar to) seizure is also one of the possible debuts of a hemorrhagic stroke. Typically, this symptom occurs in 10% of patients with a lobar stroke.

In case of impaired consciousness, it is necessary to prevent the retraction of the tongue, to prevent overlap respiratory tract. Before the arrival of the ambulance, the victim should be laid in a horizontal position, his head slightly raised.

Up to 90% of patients with GI have a disorder of consciousness upon admission to the clinic. In some patients, the regression of consciousness is gradual, from deafness and below, up to coma. Call immediately at the first sign of a stroke ambulance. It is very important!

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%.

In about 2-15% of cases, the causes of hemorrhagic stroke remain unrecognized. In the history of 25% of patients there are references to acute disorders of cerebral circulation of unclear etiology.

The main proven causes of hemorrhagic stroke:

Arterial hypertension;

Atrial fibrillation;

Diseases of the cardiovascular system;

Sedentary lifestyle.

Causes of GI that a person can correct on their own

Simple regular stroke prevention, based on knowledge of the pathophysiology of the cardiovascular system, reduces the risk of strokes and premature death by 10-30% in people who take care of their health.

Arterial hypertension

High blood pressure is recorded in 70-80% of stroke survivors.

Prolonged hypertension is accompanied by a loss of elasticity, forced vasodilation, and thinning of their walls. A sharp jump can provoke a rupture of the walls of the vessels of the brain.

Men/women under 40:

• optimal - 120/80 mm Hg;

  normal - 130/85 mm Hg

Men:

• from 40 to 49 years old - 150/98 mm Hg.

  from 49 to 79 years old - 155/103 mm Hg.

Women:

• from 40 to 49 years 150/94 mm Hg

  from 49 to 79 years 177/97 mm Hg

Drug correction of blood pressure is an important factor in the prevention of stroke. Decrease in pressure by 5 mm Hg. reduces the risk of stroke by 14%, the risk of death by 7%.

Correction must be started at pressure:

above 140/90 in a population of people with no history of cardiovascular disease;

above 130/85 in the population of people suffering from ischemic heart disease, diabetes, cerebrovascular pathologies.

For self-monitoring of blood pressure, automatic and semi-automatic blood pressure monitors are recommended, with a shoulder or wrist cuff (Omron, Nissei, AND, others). The choice of drugs should be agreed with the cardiologist. Referrals to a cardiologist ""on a quota"" can be obtained from a general practitioner at the local polyclinic. The examination can also be done for a fee at the cardiology center.

Violation of lipid metabolism with an excess of low density leads to a narrowing of the lumen of the brain vessels, deterioration in the nutrition of the nervous tissue, a decrease in the function of brain activity and the development of atherosclerosis.

Atherosclerosis, including at the subclinical stage, is the cause of the onset of hemorrhagic stroke. Normal level:

total cholesterol - up to 5.0 mmol / l;

low density lipoproteins (LDL) - 2.6-3.3 mmol / l;

high density lipoproteins (HDL) - 1.03-1.52 mmol / l.

With an elevated level of LDL, the choice of drugs must be agreed with the therapist. Correction of cholesterol levels is carried out by pharmacological agents - statins, fibrates, niacin. Statins are very effective in ischemic strokes, less effective in cerebral hemorrhages.

Diabetes

Fasting plasma glucose levels:

less than 6.1 mmol / l - normal level;

from 6.1 to 7.0 mmol / l - a harbinger of carbohydrate metabolism disorders;

more than 7.0 mmol / l - diabetes mellitus (clinical confirmation required).

Whole blood glucose levels vary. Portable devices for self-monitoring of blood glucose levels are commercially available. The devices have a built-in high/low glucose notification function. In Russia, portable glucometers of the OneTouch series, Omelon and others are recommended for use. Therapeutic adjustment of carbohydrate metabolism will be agreed with the doctor, the choice of pharmaceuticals depends on the type of diabetes.

Pregnancy and postpartum

Hemorrhagic stroke in the postpartum period is diagnosed in 30% of cases of all strokes in women aged 30-40 years

Subcortical hemorrhages are more common, less often - hemorrhages in the parenchyma. Hemorrhages are usually caused by massive birth blood loss and related disorders in the work of the cardiovascular system. Treatment is carried out taking into account the nature of the identified pathology.

Smoking

Smoking is one of the main causes of stroke. The stimulating effect of nicotine on the pathogenesis of atherosclerosis has been proven. Quitting smoking significantly reduces the risk of stroke. (cm. )

Sedentary lifestyle

The call to play sports applies more to young people. For seniors and the elderly, it is enough to do moderate exercise as part of a group of people of the same age, or to walk regularly in the fresh air.

Acute period of hemorrhagic stroke

Upon admission of the patient to the clinic, neuroimaging of the brain and a clinical assessment of the patient's condition are performed before urgent therapeutic measures are taken.

Symptoms of the acute period of GI that are important for determining the prognosis of the disease

The following symptoms are considered unfavorable (except for disorders of consciousness):

The volume of hematoma in the substance of the brain is more than 7 cm 3;

The volume of intraventricular hemorrhage is more than 2 cm 3;

Age group patient aged 60 years and older;

Arterial hypertension;

Concomitant chronic pathology;

dislocation syndromes.

Dislocation syndromes are clinical manifestations of acute brain disorders that develop as a result of a pathological expansion of the brain volume when its normal location (location) in the skull changes.

Nine variants of displacement of the medulla in the cranium relative to the usual location are known, including two main ones that are of vital importance in strokes.

The displacement of the brain towards the anatomical formations is characterized by the following symptoms:

Temporo-tentorial, cerebellar-tentorial herniation - accompanied by nystagmus (rhythmic movements of the eyeballs), paresis of the gaze (the gaze is not able to follow the movement of the object), decreased response to light, muscle atony, arrhythmia on the ECG;

Cerebellar tonsils into the foramen magnum - accompanied by pathological types of arrhythmic breathing, the disappearance of the pharyngeal reflex, a decrease in muscle tone and blood pressure.

Other symptoms of poor prognosis of intracranial hemorrhage

The study should be carried out only by a trained doctor, since incompetent manipulations can aggravate the patient's serious condition.

The symptoms are as follows:

Anisocoria - different pupil diameters;

Decreased pupillary response to light;

Positive oculocephalic reflex - in a person in a coma, with a violent turn of the head, the pupils are displaced in the opposite direction from the tilt;

Bulbar syndrome - impaired speech, sound pronunciation and swallowing, lethargy of the muscles of the tongue and lips;

Pseudobulbar syndrome - the same signs as with bulbar syndrome, but there is no lethargy of the muscles of the tongue and lips, but there is an unreasonable crying and laughter of the patient.

The patient's condition is studied in the dynamics of pathogenesis. Hemorrhagic strokes are characterized by two peaks of exacerbation of the disease, which coincide with the maximum mortality of patients:

On the second or fourth day - the peak is associated with the onset of pathogenesis in the focus of hemorrhagic stroke;

On the tenth-twelfth day - the peak is due to the addition of complications of pathogenesis.

Coma in hemorrhagic stroke

Approximately 90% of patients with GI in a state of stupor or coma die in the first five days, despite intensive therapy.

Disorders of consciousness are characteristic of many pathologies, manifested by inhibition of the functions of the reticular formation of the brain.

Brain dysfunction develops under the influence of:

Endo- and exotoxins - derivatives of the end products of metabolism;

Oxygen and energy starvation of the brain;

Metabolic disorders in brain structures;

Expansion of the volume of the substance of the brain.

Of greatest importance in the development of coma are acidosis of the brain, increased intracranial pressure, impaired microcirculation of fluids of the brain and blood.

The state of coma affects the functioning of the respiratory system, excretion (kidneys) of digestion (, intestines).

Getting out of a coma at home is impossible, and very difficult even in intensive care.

The clinical definition of coma is carried out according to the GCS (Glasgow Coma Scale), some other methods that are important for clinicians are used. Allocate precoma and four stages of coma. The easiest is the first, and the hopeless state of the patient corresponds to the fourth stage of coma.

Passage of medical and social examination

A patient who has had a stroke is defined as a person who has temporarily lost his ability to work (VUT). With an unfavorable labor prognosis after 3 months from the start of treatment, the question arises of sending a person to a medical and social examination (MSE) for examination for:

Disability (there are no prospects for the restoration of functions);

Continuation of treatment sick leave(there is a possibility of positive dynamics and restoration of functions).

The ITU Bureau makes a decision based on the data of an objective examination of the patient, the results of instrumental and laboratory studies.

What should be considered before the examination for disability?

Which doctors do you need to see?

Clinical conclusions required by the ITU Bureau:

Cardiologist;

Endocrinologist;

Optometrist;

Neurologist/therapist.

List of laboratory and instrumental studies required by the ITU Bureau:

General and biochemical parameters of blood;

ECG, rheoencephalography (REG), electroencephalogram (EEG);

Computed tomography (CT), magnetic resonance imaging (MRI);

X-ray in different projections of the cranium and cervical vertebrae, including with contrast;

Doppler ultrasound of the vessels of the neck and brain (USDG) / transcranial Dopplerography (TCDG);

Lumbar puncture (according to indications).

Specialists of the ITU bureau conduct an examination of the patient's ability to work according to several indicators, including the following:

The severity of pyramidal disorders (the ability to move, the ability to overcome obstacles, the coordination of body position in space, the severity of paresis;

The severity of extrapyramidal disorders (problems with speech, slowness in performing habitual actions, chorea, athetosis, choreoathetosis, hemiballismus, myoclonus, facial hemispasm);

The state of the functions of the organs of vision (hemianopsia, narrowing of the visual field, amaurosis, amblyopia, visual agnosia, decreased detailed vision);

The state of brain functions (aphasia, motor deficit, difficulty in communication);

Attacks of epileptic seizures (focal / partial, generalized);

Violation of mental functions (asthenia, dementia, decreased intellectual status, cognitive defects).

Factors taken into account by the ITU commission before making a decision:

Unfavorable course of the disease, the possibility of recurrence of stroke;

Unclear labor prognosis, preservation of brain activity disorders, slow recovery of functions;

The inability to return to work, the decrease in intellectual and physical capabilities below the level required to continue working under the same conditions.

Groups of disability in hemorrhagic stroke:

Group III involves a return to work, while taking into account the need to create facilitated working conditions;

Group II assumes the presence of restrictions on the ability to move, orientation and self-service;

Group I involves pronounced disorders, loss of the ability to self-service and the ability to move around, and a decrease in intelligence.

Treatment of hemorrhagic stroke

There is a generally accepted algorithm for choosing a method of therapy for hemorrhagic stroke.

Surgical tactics are indicated for:

Lobar and lateral hemorrhages of medium and large volume;

Deterioration of the patient's condition in the dynamic study of CT / MRI;

Hematomas of the cerebellum and brain stem, causing neurological symptoms.

Surgical contraindications:

Deep coma with stem dysfunctions (100% lethality);

Medial hematomas of any size (mortality rate 90-100%).

Conservative therapy is indicated for:

The stable condition of the patient and the absence of neurological deficit;

Small supratentorial hematomas.

There are two main approaches to the operation, namely:

Classical microneurosurgical interventions;

Endoscopic techniques of microneurosurgery.

Visual verification of hematomas before surgery includes CT, MRI studies, angiography of cerebral vessels and other studies according to indications.

Surgical intervention is prescribed according to the results of neuroimaging:

The volume of VMG is more than 30 ml;

Dislocation of brain tanks;

Deterioration of clinical and neurological status.

Taking into account the qualification training of the surgical team, the best results are shown by the endoscopic technique (sparing, makes it possible to visualize the operation cavity). The classical method of microsurgical intervention is good for difficulties in controlling the homeostasis of the brain tissue.

Conservative therapy and prevention

Here we present drugs of different pharmacological groups used for the treatment of the acute period of hemorrhagic stroke. Regulation of blood pressure and angiospasm is necessary in the acute period of hemorrhagic stroke.

Antihypertensive drugs:

Selective beta-blockers (Atenolol, Metoprolol, Betaxolol, Bisoprolol, Nebivolol, Esmolol, Acebutolol);

Non-selective beta-blockers (Anaprilin, Nadolol, Sotalol, Timolol, Oxprenolol, Pindolol, Penbutolol);

Mixed beta-blockers (Carvedilol, Labetalol).

calcium antagonists:

First generation (Isoptin, Finoptin, Fenigidin, Adalat, Corinfar, Kordafen, Kordipin, Diazem, Diltiazem);

Second generation (Gallopamil, Anipamil, Falipamil, Isradipine/Lomir, Amlodipine/Norvasc, Felodipine/Plendil, Nitrendipine/Octidipine, Nimodipine/Nimotop, Nicardipine, Lacidipine/Lacipil, Riodipine/Foridon);

Third generation (Klentiazem).

Antispasmodics:

Direct action (Papaverine, No-shpa, Drotaverine, Nitroglycerin, Otilonium bromide, Mebeverine, Halidor, Gimekromon);

Indirect action (Aprofen, Ganglefen, Atropine, Difacil, Buscopan).

ACE inhibitors (angiotensin-converting enzyme):

Sulfhydryl group (Benazepril, Captopril, Zofenopril);

Carboxyl group (Cilazapril, Enalapril, Lisinopril, Perindopril, Quinapril, Ramipril, Spirapril, Trandolapril);

Phosphinyl group (Fosinopril).

The following auxiliary medicines are used to treat hemorrhagic stroke:

Sedatives (Diazepam, Elenium, Phenobarbital);

Hemostatic (Dicinone / Etamzilat, Rutin, Vikasol, Ascorbic acid);

Antiprotease (Gordoks, Kontrykal);

Multivitamins with micro and macro elements (Calcium pantothenate, calcium gluconate);

Antifibrinolytic (Gamma-aminocaproic acid, Reopoliglyukin);

Nootropic (Cortexin);

Laxatives (Regulax, Glaxena).

Preparations for the regulation of intracranial pressure and cerebral edema:

Diuretics (Mannitol, Lasix);

Corticosteroids (Dexamethasone);

Plasma substitutes (Reogluman).

Thus, hemorrhagic stroke is a severe form of acute disorders of cerebral circulation, which is characterized by a high level of mortality and disability. Recovery period may take up to two years. Rehabilitation is aimed at teaching the patient how to overcome the neurological deficit. Disability is accompanied by a significant decrease in the quality of life of the patient and his environment.

Education: In 2005, she completed an internship at the First Moscow State Medical University named after I.M. Sechenov and received a diploma in Neurology. In 2009, she completed her postgraduate studies in the specialty "Nervous Diseases".

is heavy and dangerous disease central nervous system. When it occurs, hemorrhage in the brain tissue. The consequences of hemorrhagic stroke can remain with the patient for life, and significantly worsen the quality of his life. Brain tissues, saturated with blood, cease to function.

This article will discuss the consequences of hemorrhagic stroke, and the main ways to treat and correct them.

What could be the consequences?

The consequences of hemorrhagic stroke depend on the location of the hemorrhage, and the volume of affected tissues. Below is a list of the main pathological conditions that can develop with a hemorrhagic stroke:

1. Death during the first day develops due to the large volume of affected brain tissue. It can also be caused by damage to the respiratory center, which is located in the brain stem.
2. Deep coma. A patient in a coma is still temporarily able to maintain vital signs. His further condition depends on the localization of hematomas in the brain. Coma can end in three ways:

• lethal outcome;
• vegetative work of the brain;
• full return to consciousness.

1. Paralysis, paresis. Paralysis and paresis are the most common consequences of hemorrhagic stroke. They have some characteristics, depending on the location of the hemorrhage. If affected left-hand side brain, immobilization is observed in the right side of the body. With a hemorrhage in the right hemisphere of the brain, movements in the left side are disturbed. With a hemorrhage in the right or left side, weakness may appear in the lower and upper limbs, or their complete immobilization. Motor functions are completely restored very rarely.
2. Speech, hearing, vision disorders. These symptoms develop when the occipital or temporal region of the brain is affected. The patient may have motor aphasia - while he generally understands someone else's speech, and wants to say something, but cannot, due to the inoperability of the language and vocal cords;
3. Swallowing disorder - develops with hemorrhage in the occipital region.
4. Loss of the ability to navigate in space - often develops with a hemorrhage in the left side of the brain.
5. Memory loss - can be at any localization, but is more often observed with damage to the right parts of the hemispheres, or the temporal region.
6. Loss of the ability to think logically, analyze facts, compare something, discover connections between events.
7. Psychological and mental deviations. Patients often develop depression.
8. Severe headaches occur in most patients who have had this disease. Headaches may occur episodically, may be chronic, or may mimic migraine. Headaches respond very poorly to symptomatic therapy, and are not relieved by analgesics. They may be accompanied by vomiting and nausea. Often headaches occur due to increased intracranial pressure, cerebral edema.
9. Epilepsy. Seizures can be generalized, or localized, in the form of Jacksonian epilepsy. They occur with hemorrhage in the frontal, occipital, or temporal regions.

Features of a coma

Coma states develop when large areas of brain tissue are affected. The patient may fall into a coma immediately, after the onset of the disease, or after a certain period, with the development of foci of necrosis of brain tissues.

The patient may remain in a coma for a long period of time. He is in the hospital. He monitors the following indicators around the clock:

• arterial blood pressure;
• heart rate;
• electrolytes such as potassium, sodium, chloride, magnesium;
• saturation;
• oxygen and carbon dioxide levels in the blood.

With proper care and supportive care, the patient can stay in this state for a long time. But if he has large amounts of nervous tissue affected, he may never regain consciousness.

In more than half of all comatose cases, patients die. They can come to their senses, but remain in a vegetative state, in which vital functions in the body are preserved, but the person, as a person, has already died. Also, there are cases of awakening from a coma, and partial restoration of the functioning of the central nervous system.

The main treatment of patients in a coma is aimed at maintaining their vital functions, and at preventing pressure sores and infectious complications. Patients undergo intravenous administration of solutions, medications.

The main components of inpatient treatment

In order for the consequences of hemorrhagic stroke to be at least a little less, treatment must be started in the first hours after the development of the disease. It should be aimed at stopping intracranial bleeding, preventing cerebral edema, and normalizing intracranial pressure.

The main components of the treatment necessary to ensure that the consequences of hemorrhagic stroke are minimal are presented in the table:

Direction of treatment	Features of the therapy
Removal or prevention of cerebral edema	Edema of brain tissues develops in response to their damage. In order for it not to develop in a patient, it is necessary to carry out the following therapy: oxygen therapy, to maintain a saturation level of 95-98%; surgical removal of a hematoma; the introduction of anticonvulsants, such as Sibazon, Diazepam, Seduxen; introduction of loop diuretics. Such as Furosemide, Lasix, Torasemide; a decrease in body temperature, which often rises in such patients.
Stabilization of arterial blood pressure	The consequences of hemorrhagic stroke are directly related to the level of blood pressure. The disease itself always occurs with severe hypertensive crises. In the absence of pressure correction, there is a high risk of recurrent stroke, in which mortality, according to statistics, approaches 100%. To control arterial blood pressure, ACE inhibitors, beta-blockers, calcium inhibitors, diuretics are used.
Stop bleeding	Sometimes, with a hemorrhagic stroke, a large vessel ruptures. And blood can flow out of it for a long time. To stop such bleeding, they resort to surgical treatment.
Sedation	Patients who have had a hemorrhagic stroke may show subcortical behavioral features for a long time. They are manifested by aggression, insomnia, anxiety. In such patients, Diazepam, Sibazon, Elanium are used for the purpose of sedation.

Rehabilitation activities

The consequences of hemorrhagic stroke can be reduced by rehabilitation methods. From the first day of the disease, you need to start massage, and the development of all joints. This will help to avoid the development of contractures, and fusion of the articular surfaces. Even if the patient is in a coma, massage and passive gymnastics should be done every day.

If the patient is conscious, classes can be held with a speech therapist, physiotherapist and other trainers. The more active the development and training of the victim, the more he will be able to restore his vital functions and return to life in society.

Hemorrhagic stroke develops due to hemorrhage in the brain tissue. Usually, this disease occurs against the background of high arterial blood pressure. Its consequences are very serious. Often, a hemorrhagic stroke ends in death, or the patient falls into a coma. To reduce the consequences of a stroke, correct and complex therapy is necessary in the first hours after the onset of the disease.

Timely treatment can not only save life itself, but also provide the patient with the restoration of some vital functions. Treatment in a hospital is aimed at preventing cerebral edema, normalizing arterial blood pressure and stopping intracranial bleeding. Rehabilitation methods should be applied in the first days. At first they consist of massage, and passive gymnastics. Then, if possible, classes are held with a speech therapist, physiotherapist, psychologist.

- acute violation of cerebral circulation with a breakthrough of blood vessels and hemorrhage in the brain. This is the most severe brain accident.

Causes of hemorrhagic stroke:

Most common cause- hypertension and arterial hypertension (in 85% of cases)
- congenital and acquired aneurysms of cerebral vessels;
- atherosclerosis;
- blood diseases;
- inflammatory changes in cerebral vessels; collagenoses; amyloid angiopathy;
- intoxication;
- beriberi.

As a result of these diseases, the functioning of the walls of the cerebral vessels (endothelium) is disrupted, and their permeability increases. And with high blood pressure, the load on the endothelium increases, which leads to the development of microaneurysms and aneurysms (saccular dilations of blood vessels). For their formation, the peculiarity of the course of the vessels of the brain, their branching at an angle of 90 degrees, also plays a role.

By localization, parenchymal (hemispheric, subcortical, in the cerebellum, stem, in the brain bridge), subarachnoid (basal and convexital) are distinguished. Perhaps the development of intracerebral hematomas, subdural hematomas.

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

Symptoms of a hemorrhagic stroke

The hemorrhage is extremely difficult. In 50 - 90% of cases, a fatal outcome is observed.

The severity of the symptoms is determined by the formation of secondary stem symptoms - swelling of the brain stem, its displacement, herniation.

The spilled blood triggers a whole cascade of biochemical reactions, leading, in the first 2 days, to the development of vasogenic cerebral edema (acute period). On the third day, delayed angiospasm develops, which leads to the development of necrotic angiopathy and calcium cell death.

A variant of the development of hemorrhage by diapedetic bleeding is possible - due to prolonged spasm of the vessel, slowing down the blood flow in it, and its subsequent persistent expansion. In this case, a violation of the functioning of the endothelium occurs, the permeability of the vessel wall increases, sweating of plasma and blood elements from it into the surrounding tissues. Small hemorrhages, merging, form hemorrhagic foci of various sizes.

You should be especially careful about headaches. It can be a harbinger of brain catastrophe.

The development of stroke is acute (apoplexy), sudden with a rapid increase in neurological symptoms.

Rapidly increasing headache - especially severe, with nausea and vomiting, "hot flashes and throbbing" in the head, pain in the eyes when looking at a bright light and when turning the eyes to the sides, red circles before the eyes, respiratory problems, palpitations, hemiplegia or hemiparesis ( paralysis of the same limbs - right-sided or left-sided), impaired consciousness of varying severity - stunning, stupor or coma. Here is the scenario for the development of hemorrhagic stroke.

Perhaps a sudden onset of the disease with the development of an epileptic seizure. Against the background of complete health on the beach, during strong emotions at work, during an injury, a person falls with a scream, throws back his head, convulses, breathes hoarsely, foam comes out of his mouth (possibly with blood due to biting the tongue).

The gaze is directed towards the hemorrhage, the patient seems to be looking at the affected side of the brain, on the side of the hemorrhage there is a wide pupil (mydriasis), possibly divergent strabismus, the eyeballs make “floating” movements, the gaze is not fixed; on the side opposite to the hemorrhage, atony (drooping) of the upper eyelid develops, the corner of the mouth hangs down, the cheek does not hold air during breathing (symptom of "sail").

Meningeal symptoms appear - it is impossible to tilt your head forward and reach your chin to chest, it is impossible in the supine position and bending the leg at the hip joint to unbend it at the knee.

The course of extensive hemorrhages in the cerebral hemisphere may be complicated by secondary stem syndrome. Respiratory disorders, cardiac activity, consciousness are increasing, muscle tone is changing according to the type of periodic tonic spasms with a sharp increase in tone in the limbs (hormetonia) and an increase in the tone of the muscles of the extensors (extensors) and relative relaxation of the flexor muscles (decerebrate rigidity), the development of alternating syndromes is possible ( syndromes that combine damage to the cranial nerves on the side of the focus of hemorrhage with disorders of movement and sensitivity on the opposite side).

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).The appearance of these symptoms is unfavorable prognostically.

At the first symptoms of a stroke, immediate assistance is required - it is necessary to call an ambulance and hospitalize the patient.

Survey

Headache, especially recurring with the same type of localization, should always lead to a consultation and examination with a neurologist. An aneurysm or other vascular pathology detected in time, timely surgical treatment can save from a brain catastrophe and even death. Therefore, magnetic resonance imaging will have to be done, possibly with the introduction of a contrast agent and in the angiography mode. The scope of examinations is assigned individually.

Consultations of an oculist, cardiologist, rheumatologist, endocrinologist, blood tests - coagulogram, lipidogram are also possible.

Hemorrhagic stroke is diagnosed clinically by a neurologist. For neuroimaging, computed tomography of the brain is performed, which immediately "sees" the primary hemorrhage.

Treatment of hemorrhagic stroke

The patient should immediately be hospitalized in a specialized department with the presence of resuscitation and a neurosurgeon. The main method of treatment - neurosurgical - to remove the spilled blood. The issue of surgical treatment is being resolved according to computed tomography and an assessment of the amount of blood flowing out and the affected area. The severity of the general condition of the patient is also taken into account. A number of tests are done, the patient is examined by an ophthalmologist, therapist, anesthesiologist.

Undifferentiated stroke treatment includes:

Normalization of the function of external respiration, respiratory resuscitation;
- regulation of the functions of the cardiovascular system;
- correction of arterial pressure;
- neuroprotection - semax 1.5% - nasal drops; ceraxon or somazin, intravenous cerebrolysin, cytochrome, cytomak.
- antioxidants - mildronate, actovegin or solcoseryl, mexidol intravenously; vitamin E.
- vasoactive drugs to improve microcirculation - trental, sermion.

Differentiated treatment of hemorrhages:

Neurosurgical treatment;
- strict bed rest, raised head end of the bed;
- if necessary - glucocorticoids, mannitol, lasix, calcium antagonists, antiserotonergic agents, protease inhibitors, aminocaproic acid, hemophobin ...
- with craniocerebral injuries - antibiotics.

The seriousness of the listed drugs excludes any initiative in prescribing.
In the subacute period and the period of consequences of hemorrhagic stroke, patients should be registered at the dispensary, treat the underlying somatic disease, and undergo neurorehabilitation courses.

subarachnoid hemorrhage

subarachnoid hemorrhage develops when an aneurysm of a vessel or other vascular malformation ruptures with hemorrhage into the subarachnoid space (a cavity between the pia mater and arachnoid meninges of the brain and spinal cord, filled with cerebrospinal fluid (CSF).

There are three stages in development:

1 outflow of blood into the subarachnoid space, spread along the liquor pathways and the development of liquor-hypertension syndrome;
2 blood coagulation in the liquor with the formation of clots, impaired liquorodynamics and the development of vasospasm;
3 dissolution of clots and release of fibrinolysis products into the cerebrospinal fluid, which enhances vasospasm.

With a favorable course, microcirculation is restored and the structure of the brain is not affected.

Symptoms of the disease: sudden headache, photophobia, dizziness, vomiting, may develop an epileptic seizure.

Immediate hospitalization in a specialized department is required.

Diagnosis: examination by an ophthalmologist - in the fundus there is swelling of the optic discs, punctate hemorrhages, hypertensive angiopathy; CT scan; lumbar puncture; magnetic resonance imaging in angiography mode, computed tomography.
Intracerebral hematomas are accumulations of liquid blood or clots in the tissues of the brain. They often occur with traumatic brain injuries and can develop within 12 to 36 hours.

The clinical picture is due to the primary damage to the brain tissue in the area of ​​hemorrhage and symptoms of hematoma impact on the surrounding brain structures - headache, loss of consciousness up to coma and focal neurological signs (hemiparesis, aphasia, convulsive seizures).

Urgent hospitalization in the neurosurgical department is indicated.

All head injuries require an examination by a neurologist and a neurosurgeon, who, if necessary, will prescribe additional examinations.

To resolve the issue of surgical treatment, computed tomography, magnetic resonance imaging, and angiography are performed.

subdural hematoma

subdural hematoma- this is a hemorrhage in the space between the dura and arachnoid meninges. Such a hematoma is dangerous by compression of the brain. Insidious subdural hematoma is the time of its development. Acute development is possible: trauma - hematoma - clinical manifestations. And the presence of a “light gap” is also possible: trauma, loss of consciousness - a light gap with practically no complaints from several hours to several days - a sharp deterioration, loss of consciousness, an increase in neurological symptoms.

Therefore, it is important to always consult a neurosurgeon in case of a head injury. Treatment - surgical - removal of the hematoma.

In all cases of hemorrhage, drug therapy is used to normalize the patient's vital functions and preserve unaffected brain neurons. Treatment is prescribed only by doctors, in specialized departments.

Prognosis after hemorrhagic stroke

Maximum mortality (mortality) from hemorrhagic stroke in the first or second day of the disease due to destruction, swelling of the brain or compression of vital centers located in the brain stem.

With a favorable course of a stroke, as consciousness clears up, focal symptoms are clearly manifested - neurological defects that depend on the location of the hemorrhagic focus - hemiplegia, hemianopsia (loss of half of the visual field), hemianesthesia (loss of sensation in half of the body and the same limbs), speech disorders (with damage to the left hemisphere), apractoagnostic syndrome (misrecognition and inability) (with damage to the right hemisphere), mental disorder (with damage to the frontal lobes of the brain). Hemiplegia is expressed by paralysis of the limbs and paralysis of the muscles of the face and tongue. At the same time, the tone of the flexor muscles in the arm increases, and that of the extensor muscles in the leg, which leads to the emergence of the characteristic Wernicke-Mann posture, to the formation of flexion contractures in the joints of the arm and extensor contractures in the joints of the leg.

The recovery period is long. The maximum possible decrease in neurological deficit occurs in the first year after the brain accident. Gradually, the intensity of recovery decreases and after three years a residual period begins, that is, a period of residual phenomena.

Doctor's consultation on hemorrhagic stroke

Question: Is there a prevention of hemorrhagic diseases?
Answer: The prevention of hemorrhagic stroke is, first of all, the control of blood pressure and body weight, smoking cessation, alcohol abuse, excessive salt intake, as well as maintaining a calm lifestyle.

Question: 3 months after the hemorrhagic stroke, the neurologist ordered a follow-up MRI - why?
Answer: to exclude fresh foci of hemorrhage, to detect the outcome of a hemorrhagic stroke, either a cyst develops (size, location matter ...) or cystic-glial changes (“cicatricial” changes), to exclude vascular malformation, to correct treatment.

Question: is it possible to fully recover after a hemorrhagic stroke?
Answer: no, there will definitely be a neurological defect. Full recovery of functions is possible with subarachnoid hemorrhage.

Question: Are there sanatoriums for the treatment of patients after strokes?
Answer: yes, but patients who are capable of self-care and do not have general contraindications are accepted there.

Neurologist Kobzeva S.V.

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.

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 occur in the arteries and arterioles of the brain parenchyma. 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

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 mild stunning to the development of a coma. The onset of subcortical hemorrhages 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, hemiparesis, frontal syndrome (in the form of memory impairment, behavior, criticism), sensitivity and speech disorders should be noted.

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. Hemorrhages with a breakthrough into the ventricular system are more severe than others, 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.

Establishing diagnosis

The main methods for diagnosing hemorrhagic stroke:

• helical CT or plain 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. At ischemic stroke cerebrospinal fluid, examined by lumbar puncture, has a normal composition, with hemorrhagic - it may contain blood.

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.

Drug therapy is carried out by a neurologist. Basics of conservative treatment of hemorrhagic stroke general principles 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 location 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. It is possible to postpone the operation only if its goal is to remove the hematoma for more effective removal 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).

Prognosis for 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 brainstem, breakthrough of blood into the ventricles, disorders of the cardiovascular system that precede hemorrhagic stroke, and the patient's advanced age.

Prevention

The main preventive measures that can prevent the development of hemorrhagic stroke are timely and adequate drug treatment hypertension, as well as the elimination of risk factors for its development (hypercholesterolemia, diabetes mellitus, alcoholism, smoking).

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