CEREBRAL HEMORRAGIA or HEMORRAGIC STROKE: causes, symptoms, therapy and prognosis

Cerebral hemorrhage or hemorrhagic stroke

L'cerebral hemorrhage it is a pathology of the cerebro-vascular district corresponding to a leak of blood from a vessel of the brain, be it arterial or venous, which causes bleeding inside the skull. This blood extravasation causes severe and rapidly progressive neurological deficits in a very short time depending on the brain area affected by the lesion. They are the second most common cause of stroke, after vascular occlusion (ischemic stroke).

Classification of cerebral hemorrhages

There are numerous classifications of cerebral haemorrhages, but the most commonly used one focuses on the site where this pathology occurs. They are divided into:

  1. Cerebral or intra-axial haemorrhages: the focus of the disease is inside the brain (they are therefore called "cerebral haemorrhages"). Intraparenchymal haemorrhages and intraventricular haemorrhages are included in this group.
  2. Extra-axial hemorrhages: the site is always inside the skull, but outside the brain nervous tissue. In this category we find epidural haemorrhages, subdural haemorrhages (subdural hematoma) and subarachnoid hemorrhages.

In this article, we will focus in particular on hemorrhages of the brain, or of the intra-axial district.

Between brain haemorrhages, we can have two possible bleeding sites:

  1. Intraparenchymal, or inside the cerebral and cerebellar parenchyma, or inside brain and cerebellum.
  2. Intraventricular, or inside the cerebral ventricles, a system of fluid-containing cisterns.

Between intraparenchymal haemorrhages, intraparenchymal hemorrhages are distinguished:

  1. TO typical location, whose localization is in the deep structures of the brain, such as basal ganglia, thalamus, pons, brainstem and cerebellum;
  2. TO atypical location, or at the level of the cerebral lobes.

All these classifications of cerebral hemorrhage they are widely used by doctors, as each of them can be correlated with a peculiar symptomatology and a different prognosis.

subdural hemorrhage

CT scan of the brain showing a left subdural hematoma.

Causes of cerebral hemorrhage

Based on the site of onset, various causes and / or risk factors are recognized that can drastically increase the incidence of this pathology. Among these, we remember causes of cerebral hemorrhage such as:

  1. High blood pressure, which causes important structural alterations in particular cerebral arterioles, predisposing them to rupture. This factor is responsible for the 60-70% of cerebral haemorrhage cases;
  2. Amyloid angiopathy, or a disease characterized by the deposition of an insoluble protein substance in the vessel walls, which alters the elasticity and structure of the vessels. This pathology induces a 40% increase in the incidence of haemorrhages in the cranial district;
  3. Vascular malformations (or MAV), such as angiomas and aneurysms, which make the vessels weaker and more prone to rupture;
  4. Using medications chronic anticoagulants or antiplatelet agents, such as warfarin (Coumadin), heparin, acetyl salicylic acid (cardioaspirin). In these cases, the patient appears to be more susceptible to the genesis of major bleeding even for minor trauma;
  5. Trauma cerebral, as the impact can cause the rupture of cerebral vessels, especially in patients who take anticoagulants in chronic;
  6. Illnesses of the coagulation, such as haemophilia, which expose the person to an increased risk of bleeding;
  7. Hemorrhages from neoplastic disease, such as melanoma or renal cell carcinoma;
  8. Chronic use of narcotic substances, including cocaine and amphetamine;

The 80% of all cerebral haemorrhages not related to anticoagulant or antiplatelet therapies in place depend on hypertension or amyloid angiopathy, therefore they are risk factors to be controlled and not to be underestimated.

Cerebral hemorrhage symptoms

In case of haemorrhage, the area affected by the haemorrhage implements mechanisms aimed at preserving the integrity of the anatomical structure, forming a swelling area around the haemorrhagic lesion, called "cerebral perilesional edema". To this condition, all the blood that comes out of the vessel is also added. The expansion of these liquids in a rigid compartment such as the skull, made up entirely of non-deformable bone, induces a condition called "intracranial hypertension", which blocks arterial circulation.

At the same time, the leaked blood will no longer carry the oxygen and nutrients that the organ needs to the brain area of competence.

What are the main symptoms of hemorrhagic stroke?

THE symptoms ofintracranial hypertension they are usually non-specific and vary according to the extent of the bleeding. We can frequently encounter alarm symptoms, such as:

  1. Severe headache, but often mild or absent in the elderly;
  2. Nausea and vomiting, frequently associated with headaches
  3. Sensation of a ringing in the ears, synchronized with the heartbeat;
  4. Bradycardia, which is a reduction in heartbeats per minute
  5. Initial lethargy and drowsiness, which can degenerate into a sudden loss of consciousness, up to a coma.

Based on the territory affected by the hemorrhage, we can also find symptoms such as:

  1. Deficits in strength, motility and coordination of one or more limbs;
  2. Inability to speak correctly
  3. Sensation of tingling and numbness in the skin;
  4. Tremors of the hands and feet;
  5. Loss of balance
  6. Different diameter of the pupils, only in cases of advanced hemorrhage;
  7. Sudden seizures even in patients who do not have a clinical history of epilepsy, as the blood, leaking from the vessels, irritates the neurons, leading to their sudden discharge;
  8. Raised body temperature, which worsens the patient's prognosis.

However, it should be remembered that all these symptoms depend exclusively on the amount of blood leaking from the vessels. In fact, small hemorrhages can cause limited deficits without compromising consciousness and ability to move in any way, but it is important that any warning signs be readily observed by an expert. The doctor, therefore, must be scrupulous and carefully monitor all the possible predisposing causes, so as to act promptly and correct the risk factors, if this is possible.

Brain Hemorrhage Diagnosis

The anamnesis of previous pathologies, pharmacological treatments and the patient's voluptuous habits is very important, as they allow us to understand the cause of the bleeding.

The symptomatology is not very specific of the disease, as it is very similar to that caused by ischemic stroke, but it allows to suspect a hemorrhage inside the skull. In the case of bleeding in progress, the cardiocirculatory and respiratory parameters are checked in the first instance, to avoid cardiorespiratory arrests and subsequent ischemia.

Blood, haematochemical and coagulation parameters tests are then performed, in order to study the patient in detail and to frame his problem in the best possible way.

Some more specific imaging tests are needed to diagnose cerebral hemorrhage. They are mainly used:

  1. Computed tomography (TC) cerebral. It is done without the aid of contrast medium in urgency, since it allows in any case to visualize the bleeding and to exclude stroke on an ischemic basis;
  2. Magnetic resonance (RM) of the brain with contrast medium, used to detect the presence of vascular malformations or previous bleeding or haemorrhages;
  3. Angiography associated with CT of the brain (cerebral CT angiography) or an MRI (MRA of the brain), to study the presence of AVMs causing bleeding. This method also allows to act directly at the level of the damaged vessel, allowing it to be closed effectively if the circumstances allow.

Hemorrhagic stroke therapy

How is this serious condition treated? Are there adequate treatments?

The therapy is based on two fundamental cornerstones:

  1. there surgical therapy, aimed at draining leaked blood, particularly in patients whose neurological conditions are rapidly deteriorating. A hole can be made at the level of the skull or the complete opening of the skull, called craniotomy, based on the location and size of the bleeding event. To date, unfortunately, there are hemorrhages in sites where surgical aggression is not possible;
  2. there medical therapy, which aims to consider in the first place all those symptoms that endanger the patient's life, such as possible cardio-respiratory arrest and intracranial hypertension, correcting the most easily attackable risk factors, such as hypertension, hyperthermia and coagulation problems. For this reason, pulmonary ventilation is ensured, by administering diuretics, such as mannitol and furosemide, and vasodilators, such as nitroprusside, for the control of systemic blood pressure and inside the skull. In this situation, however, it is not necessary to bring the values of the systemic pressure back to a normal range, as it would risk having a condition of poor cerebral perfusion, further deleterious. Based on the patient and the anticoagulant therapy followed by him, preparations capable of normalizing normal blood coagulation can be administered. First, platelet and prothrombin concentrates can be given, but factors such as protamine and vitamin K can be used, even by virtue of possible subsequent surgery.

Prognosis

There prognosis of this pathology and neurological recovery depend in particular on the size of the bleeding, the triggering cause and its location, as well as the age and clinical status of the patient before the haemorrhagic event. The patient can also run into non-neurological problems, such as infections and arrhythmic changes of the heart, which can affect the course of the disease. Mortality within thirty days is 50%, while the presence of high disability one year after the haemorrhagic event affects up to one third of patients.

Rehabilitation

There rehabilitation it is based on the recovery of lost functionality both from the cognitive point of view, both from the motor point of view and from the point of view of sensitivity. In some cases, a good part of the problems that occurred following the bleeding can be restored up to the return to normal work activities, but it is essential that the patient follows the therapy prescribed by the doctor and that rehabilitation treatment begins as soon as possible. There are numerous effective protocols used by specialists for cognitive recovery, among which the one mainly used is the Perfetti method. From a motor point of view, the cooperation between neurologist, physiatrist and physiotherapist is fundamental, who will draw up a recovery plan adapted to the patient's general and neurological needs and conditions.

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