bubble_chart Overview

It refers to non-traumatic hemorrhage within the brain parenchyma. The most common causes are hypertension and atherosclerosis coexisting, while rare causes include congenital cerebrovascular malformations or aneurysms, blood disorders, anticoagulation or thrombolytic therapy, cerebral arteritis, etc.

bubble_chart Diagnosis

1. Medical History and Symptoms:

Most patients have a history of hypertension, and the condition is more common in middle-aged and elderly individuals, with a higher incidence during cold seasons. The onset often occurs during physical activity, characterized by sudden severe headache accompanied by vomiting, frequent disturbances in consciousness, and elevated blood pressure at onset. The focal neurological signs are related to the location and volume of the hemorrhage. History-taking should focus on understanding the above-mentioned details.

2. Physical Examination Findings:

- Varying degrees of impaired consciousness, often with significantly elevated blood pressure in the early stages. Severe cases may present with bounding and slow pulse, deep and slow respiration, and frequent central high fever. Worsening conditions may lead to central respiratory and circulatory failure. Irregular pupil shape, bilateral constriction or dilation, unequal pupil size, and sluggish or absent light reflex. Positive meningeal irritation signs. Fundoscopy may reveal retinal artery sclerosis and retinal hemorrhage, occasionally with papilledema. Upper gastrointestinal bleeding, arrhythmia, pulmonary edema, etc., may also occur.

- Localized signs:

① Putaminal hemorrhage mainly presents with the "three biases" (hemiplegia, hemianopia, and hemisensory impairment), conjugate gaze deviation, and aphasia if the left hemisphere is affected;

② Thalamic hemorrhage may exhibit hemiplegia, hemisensory impairment, vertical gaze palsy and convergence insufficiency, and constricted pupils;

③ Lobar hemorrhage shows mild consciousness impairment, frequent seizures and prominent meningeal irritation signs, with focal signs varying depending on the affected lobe;

④ Pontine hemorrhage manifests as deep unconsciousness, pinpoint pupils, high fever, decerebrate rigidity, or quadriplegia (in severe cases), while milder cases present with crossed paralysis and sensory deficits, as well as ocular motility disorders (extraocular muscle palsy, conjugate gaze palsy, internuclear ophthalmoplegia);

⑤ Cerebellar hemorrhage features vertigo, nystagmus, and ataxia (in mild cases), while severe cases present with unconsciousness and flaccid limbs;

⑥ Intraventricular hemorrhage is characterized by pinpoint pupils, deep unconsciousness, high fever, and decerebrate rigidity.

3. Auxiliary Examinations:

- Cranial CT can reveal the location, extent, and volume of hemorrhage, whether blood has entered the ventricular system, perilesional edema, and midline shift;

- Lumbar puncture: elevated cerebrospinal fluid pressure with uniformly bloody CSF;

- Transient peripheral leukocytosis, elevated blood glucose and blood urea nitrogen, grade I proteinuria, and glycosuria may occur during the acute phase.

- ECG may show abnormalities consistent with hypertensive heart disease.

4. Differential Diagnosis:

- For patients with impaired consciousness, systemic diseases causing unconsciousness should be ruled out; - For those with focal neurological signs, other intracranial space-occupying lesions, meningoencephalitis, and closed head trauma should be differentiated; - Additionally, cerebrovascular diseases such as cerebral infarction and subarachnoid hemorrhage should be distinguished.

bubble_chart Treatment Measures

1. Maintain airway patency, avoid unnecessary movement, and closely monitor changes in consciousness, pupils, and vital signs.

2. Administer oxygen and apply local physical cooling to the head. Options include 20% mannitol, furosemide, glycerol, and dexamethasone to reduce intracranial pressure.

3. If blood pressure remains high after using intracranial pressure-lowering medications, administer reserpine 0.5–1 mg intramuscularly or nitroglycerin 10 mg sublingually.

4. For patients with coagulation disorders, administer 6-aminocaproic acid 4–6 g or tranexamic acid 100–200 mg intravenously, twice daily.

5. Fast for 1–2 days initially. During fasting, provide daily fluid replacement of approximately 2000 ml (500 ml glucose saline, 1000–1500 ml glucose solution, and 4 g potassium). After 2–3 days, introduce milk via nasal feeding in small, frequent amounts, gradually increasing the volume.

6. Prevent and treat complications: For upper gastrointestinal bleeding, select appropriate hemostatic agents, such as Reptilase 10 µ once daily, or administer 100 ml ice saline with 8 mg norepinephrine via nasal feeding. Intravenously administer cimetidine 200 mg 3–4 times daily or omeprazole injection 40 mg 1–2 times daily. Prevent pneumonia and bedsores. Additional treatments: For cases with clear localization, perform intracranial hematoma puncture and aspiration (putamen hemorrhage) or anterior horn ventricular drainage (thalamic hemorrhage rupturing into the ventricles or cerebellar hemorrhage). For putamen, lobar, or cerebellar hemorrhage, consider craniotomy for hematoma evacuation in the early or pre-herniation stage. During the acute phase, use brain cell activators such as coenzyme Q10, pyritinol, or cerebrolysin.

7. During the convalescence stage, combine traditional Chinese medicine and acupuncture therapy, intensify limb functional exercises, language training, and blood pressure control treatment. {|106|}