The causes of this disease are numerous and varied. They differ according to patient age.
The most common cause of cerebral hemorrhage is hypertension (occurs with predilection for the elderly). Bleeding, in this case, is located in deeper areas of the brain, because in these areas are small penetrating arteries which break more easily to acute increases in blood pressure and regional cerebral blood flow.
Other causes of cerebral hemorrhage may include: cerebral vascular malformations, sympathomimetic drugs, arteritis (inflammation of the arterial wall), tumors (especially malignant), amyloid angiopathy, cerebral thrombophlebitis, hemodialysis.
After anticoagulant or fibrinolytic treatment (streptokinase, Urokinase) or antiplatelet (aspirin, clopidogrel) bleeding may occur and affect the white matter of brain lobes.
Both hemorrhagic and ischemic strokes may occur during pregnancy, predisposing causes are the hypercoagulable states, eclampsia (characterized by seizures or even coma, outside of brain pathology or other; may occur in the last months of pregnancy during labor or during the first days postpartum) or presence of intracranial vascular lesions.
Cerebral hemorrhage can occur through two mechanisms: rupture of arterial vessels (generally occurs in patients with hypertension) and diapedesis (figurative elements of blood passing through the walls of blood vessels).
The bleeding is located within the parenchyma, the clinical picture changes depending on the location of the bleeding, the bleeding speed, the volume and collection of blood which makes pressure on neighboring structures.
The symptoms of cerebral haemorrhage are general and specific signs (depending on location of the bleeding).
General symptoms are common to any locations, characterized by abrupt onset with headache, vomiting, seizures, changes in consciousness that can evolve to coma, neck stiffness, and possibly hyperthermia.
Specific signs are guiding topographic diagnosis (location of the bleeding). They are represented by a series of motor deficits (hemiplegia, hemiparesis), sensitive deficits (hemianesthesia, hemihipoesthesia), sensory deficits (impaired olfactory, visual), language disorders, balance disorders.
Among systemic complications of cerebral hemorrhage there are acute pneumopathies, urinary tract infections, gastrointestinal bleeding, pulmonary embolism, cardiac disorders.
The method for evaluation of acute cerebral hemorrhage is computer tomography.
Evolution and prognosis depend on a number of factors, as follows:
– Major bleeding with brutal onset, with rapid input to coma have poor prognosis (unfavorable)
- Small hemorrhages under 3 cm in diameter, moving well, with spontaneous recovery under close supervision;
– Bleeding of intermediate sizes may evolve differently, whether favorable or the neurological deficit is widening and consciousness changes, evolving to coma.
Treatment is established as early as possible and consists of:
– Oral-tracheal intubation with mechanical breathing – for comatose patients with respiratory disorders;
– Blood pressure is gradually decreased – using beta-blockers;
– Combating cerebral edema – Mannitol is performed;
– If convulsions – is administered diazepam or phenobarbital;
– Bleeding consecutive to oral anticoagulants – is given vitamin K;
– Bleeding secondary to treatment with heparin – protamine sulfate is administered;
– Hemorrhage caused by thrombolytic agents – use plasma or aminocaproic acid;
– Antibiotics – in patients with fever or catheterization;
– Surgery – is debatable depending on the size of bleeding and clinical condition of the patient.
Bibliography: 1. Braunwald's Heart Disease; 2. Harrison's Principles of Internal Medicine; 3. European Society of Cardiology - Clinical Practice Guidelines.