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    Home > Active Ingredient News > Study of Nervous System > Classification, diagnosis and treatment of cerebral hemorrhage, this article clarifies!

    Classification, diagnosis and treatment of cerebral hemorrhage, this article clarifies!

    • Last Update: 2022-09-22
    • Source: Internet
    • Author: User
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    Solid foundation


    Intracerebral hemorrhage (ICH) is a common and refractory disorder
    .

    According to the data of the "Screening and Intervention Project for High-risk Groups of Stroke" in 2018, the number of stroke patients aged 40 and above in China reached 12.
    42 million, of which cerebral hemorrhage accounted for 25% to 55%
    of stroke patients.
    Among stroke patients, the disability and mortality rate of intracerebral hemorrhage patients is higher than that of cerebral infarction patients, the one-month mortality rate of cerebral hemorrhage patients is as high as 35% to 52%, and about 80% of surviving patients at the end of 6 months are still disabled, which is one
    of the main causes of death and disability of Chinese residents.

    Standardizing the diagnosis and treatment standards of cerebral hemorrhage is conducive to reducing its mortality and disability rates
    .
    Classification of one-brain hemorrhage ➤ Classification according
    to the site of bleeding According to the location of cerebral hemorrhage, it can be divided into the following types: (1) basal nucleus area bleeding; (2) Thalamus hemorrhage; (3) Lobular hemorrhage; (4) Brainstem hemorrhage; (5) Cerebellar hemorrhage; (6) Ventricular hemorrhage
    .

    Among them, thalamus hemorrhage is often combined with lateral ventricular hemorrhage, cerebellar hemorrhage can be combined with quadrangular hemorrhage, and in severe cases, it can be cast
    .
    ➤ Risk factors and causes of
    cerebral hemorrhage are more common
    in hypertension, cerebral amyloid vascular disease (CAA), cerebral arteriovenous malformations, cerebral aneurysms, tumor strokes, and coagulation dysfunction.
    At present, there is no unified etiological classification standard for cerebral hemorrhage at home and abroad, mainly according to blood pressure classification (hypertensive cerebral hemorrhage and non-hypertensive cerebral hemorrhage), SMASH-U classification, classification according to vascular lesions and pathogenesis, classification by etiology (primary cerebral hemorrhage and secondary cerebral hemorrhage) and other types
    .
    Among them, primary cerebral hemorrhage and secondary intracerebral hemorrhage are more commonly recognized
    .
    (1) Primary cerebral hemorrhage: mainly hypertensive cerebral hemorrhage, a few are cerebral amyloid vascular disease and unexplained cerebral hemorrhage
    .

    According to the analysis of existing literature, up to 70% to 80% of patients with primary cerebral hemorrhage and hypertension in China
    .

    Primary intracerebral hemorrhage accounts for approximately 80% to 85%
    of all intracerebral hemorrhages.
    (2) Secondary cerebral hemorrhage: generally refers to cerebral hemorrhage with a clear cause, mostly caused by cerebral arteriovenous malformations, cerebral aneurysms, anticoagulants, thrombolytic therapy, antiplatelet therapy, coagulation dysfunction, brain tumors, cerebral vasculitis, dural arteriovenous fistula, Moyamoya disease, venous sinus thrombosis, etc.
    , accounting for 15% to 20%
    of cerebral hemorrhage.

    Diagnosis of bicephalus
    hemorrhage

    Overall diagnostic criteria


    (1) Acute onset
    .
    (2) Focal nerve function defect symptoms (a few are comprehensive nerve function defects), often accompanied by headache, vomiting, increased blood pressure and different degrees of consciousness disorders
    .
    (3) Head CT or MRI shows bleeding foci
    .
    (4) Exclude non-vascular brain causes
    .

    Diagnostic criteria related to etiological typing


    ➤ There is no gold standard for the diagnosis of hypertensive cerebral hemorrhage
    , and it is necessary to exclude various secondary cerebral hemorrhage diseases to avoid misdiagnosis, and the final diagnosis needs to meet all the following criteria
    .

    (1) Have a definite history
    of hypertension.
    (2) Typical bleeding sites, such as basal nucleus region, thalamus, ventricles, brainstem, cerebellar hemispheres, etc
    .
    (3) Digital subtraction angiography (DSA)/CT angiography (CTA) and magnetic resonance angiography (MRA) to exclude secondary cerebrovascular disease
    .
    (4) Exclude various coagulation disorders
    .
    (5) Early (within 72 hours) or advanced stage (2 to 3 weeks after the hematoma is fully absorbed) Enhanced MRI examination is performed to exclude brain tumors or cavernous vascular malformations and other diseases
    .
    ➤CAA-related cerebral hemorrhage is widely used in clinical practice at home and abroad, and the improved Boston diagnostic criteria are widely used, combined with pathology and its imaging characteristics, according to the likelihood of CAA-related cerebral hemorrhage, divided into the following types:
    (1) Confirmed CAA: Comprehensive autopsy suggests lobular, cortical or subcortical hemorrhage; The presence of severe CAA with vascular lesions; No other lesions are suggested
    .
    (2) CaA with pathological support is likely: clinical data and pathological tissue (cleared hematoma or cortical biopsy) show that there is bleeding in the lobes, cortical or subcortical; There is some degree of CAA; No other lesions are suggested
    .
    (3) It is likely that CAA: clinical data and MRI/CT suggest that there is excessive bleeding limited to the lobes, cortex or subcortical (cerebellar hemorrhage may be present); or single lobe, cortical or subcortical hemorrhage, with localized (1 to 3 sulcus) or scattered superficial iron deposits in the brain; Age ≥ 55 years; Other causes of bleeding are excluded
    .
    (4) May BE CAA: clinical data and MRI/CT indication: single lobe, cortex or subcortical hemorrhage; Concomitant limited (1 to 3 sulcus) or scattered superficial iron deposition of the brain; Age ≥ 55 years; Rule out other causes of intracerebral hemorrhage
    .
    In recent years, studies have shown that imaging features combined with genotype can improve the diagnostic accuracy of CAA cerebral hemorrhage, including APOEε4 genotype, combined subarachnoid hemorrhage, and peripheral indications of
    hematoma.

    Diagnostic process


    (1) Is it a stroke? Judged by onset, history, and signs
    .
    (2) Is it a cerebral hemorrhage? Brain CT or MRI confirms
    .
    (3) How serious is the hemorrhage? Assessed on imaging tests of the location of intracerebral hemorrhage and the amount of bleeding, in conjunction with the Glasgow Coma Scale (GCS) or the National Institutes of Health Stroke Scale (NIHSS) scale
    .
    (4) Causes of cerebral hemorrhage? Confirmed by history, signs, laboratory, and imaging
    .
    Based on clinical symptoms and signs such as sudden onset, severe headache, vomiting, and neurological dysfunction, combined with imaging tests such as CT, it is generally not difficult to diagnose
    cerebral hemorrhage.
    In clinical work, the diagnosis and recommendation process for the cause of cerebral hemorrhage can be referred to (Figure 1) to improve the examination to find the cause
    more accurately.
    Figure 1 Diagnosis of the cause of cerebral hemorrhage Recommended Procedure Three Treatment of cerebral hemorrhage Includes medical treatment and surgical treatment, most patients are mainly internal treatment, if the condition is critical or found to have a secondary cause, and there are surgical indications, surgical treatment
    should be performed.

    Medical treatment


    ➤ General treatment

    Patients with intracerebral hemorrhage are often unstable in the first few days after onset of illness and should be routinely monitored for ongoing vital signs, neurologic evaluation, and continuous cardiopulmonary monitoring, including cuff blood pressure monitoring, ECG monitoring, and oxygen saturation monitoring
    .

    The principles of oxygen inhalation, respiratory support and heart disease in patients with cerebral hemorrhage are the same as those in China's Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2018
    .


    ➤ Blood pressure management
    recommendations:
    (1) The blood pressure of patients with cerebral hemorrhage should be comprehensively managed, the causes of blood pressure increase should be analyzed, and then the decision should be made on whether to carry out antihypertensive therapy according to the blood pressure situation (grade I recommendation, grade C evidence).

    (2) For hospitalized patients with systolic blood pressure of 150 to 220 mmHg, in the absence of contraindications to acute antihypertensive, it is safe to reduce blood pressure to 130 to 140 mmHg within a few hours (Grade II recommendation, Grade B evidence), and its effectiveness in improving patient neurological function needs to be further verified (Grade II recommendation, Grade B evidence); In patients with intracerebral hemorrhage with systolic blood pressure > 220 mmHg, it may be reasonable to continuously administer drugs to control blood pressure with a Systolic Blood Pressure Target value of 160 mmHg (Grade II recommendation, Grade D evidence)
    with close monitoring of blood pressure.
    (3) During antihypertensive therapy, the changes in blood pressure levels should be closely observed, blood pressure fluctuations should be avoided, and blood pressure monitoring should be carried out every 5 to 15 minutes (grade I recommendation, C grade evidence).

    ➤ Blood glucose management
    recommendations: Blood glucose values can be controlled at 7.
    8 to 10.
    0 mmol/L
    .

    Blood glucose monitoring should be strengthened and treated accordingly: (1) insulin therapy can be given when blood glucose exceeds 10 mmol/L; (2) When the blood glucose is lower than 3.
    3 mmol/L, 10% to 20% glucose can be given orally or injected
    .

    The goal is to reach normal blood glucose levels
    .
    ➤ Central fever may occur early in patients with intracerebral
    hemorrhage, particularly in patients with massive intracerebral hemorrhage, thalamus hemorrhage, or brainstem hemorrhage
    .

    The duration of fever within 72 hours of admission was associated with clinical outcome, however, there are no data to suggest that treatment of fever improves clinical outcome
    .

    After 3 days of onset, patients can have fever due to infection and other reasons, and the cause should be treated
    at this time.
    ➤ Drug therapy
    (1) Hemostasis therapy
    recommendation: The clinical efficacy of recombinant factor VII.
    a (rFVII.
    a) in the treatment of cerebral hemorrhage is uncertain and may increase the risk of thromboembolism, and routine use is not recommended (grade I recommendation, grade A evidence).


    Tranexamic acid helps limit hematoma volume enlargement and reduce early case fatality, but long-term benefit is uncertain and no selective use is recommended (grade II recommendation, grade A evidence).

    (2) Other treatment
    recommendations: the efficacy and safety of neuroprotective agents and traditional Chinese medicine preparations need to be further confirmed by more high-quality clinical trials (Level II recommendation, Grade C evidence)

    Treatment of the cause


    Recommendation: (1) When cerebral hemorrhage occurs with antithrombotic drugs, the drug should be stopped immediately (Grade I recommendation, Grade B evidence).

    (2) Patients with warfarin-associated cerebral hemorrhage may consider prothrombin concentrate complex (PCC) as an alternative to fresh frozen plasma (FFP) (grade II recommendation, grade A evidence) with intravenous vitamin K (grade I recommendation, grade C evidence).


    For cerebral hemorrhage associated with novel oral anticoagulants (dabigatran, apixaban, rivaroxaban), appropriate antagonistic drugs (eg, edetazizumab) can be used in patients with conditions (grade II recommendation, grade C evidence).

    (3) rFVII.
    a monotherapy for oral anticoagulant-related cerebral hemorrhage is not recommended (grade IV recommendation, grade D evidence).

    (4) For unfractionated heparin-related cerebral hemorrhage, it is recommended to use protamine sulfate for treatment (grade II recommendation, grade C evidence).

    (5) For thrombolytic drug-related cerebral hemorrhage, transfusion of coagulation factors and platelet therapy can be selected (grade II recommendation, grade B evidence).

    (6) For the use of antiplatelet drug-related cerebral hemorrhage, conventional platelet transfusion therapy is not recommended (grade I recommendation, grade A evidence).

    Treatment of complications


    ➤ Recommended opinion on the management of
    increased intracranial pressure: those with increased intracranial pressure should be bedridden, moderately elevated bedside, and closely observed for vital signs (grade I recommendation, grade C evidence).


    When dehydration and cranial pressure reduction are required, intravenous infusions of mannitol (grade I recommendation, grade C evidence) and hypertonic saline (grade II recommendation, grade B evidence) should be given, and the dosage and course of treatment are individualized
    .

    At the same time, pay attention to monitoring the heart, kidneys and electrolytes
    .

    If necessary, furosemide, glycerol fructose, and/or albumin (grade II recommendation, grade B evidence)
    may also be used.

    Ventricular drainage may be performed in patients with hydrocephalus with impaired consciousness to relieve increased intracranial pressure (grade II recommendation, grade B evidence).

    ➤ Epileptic seizures
    recommended:
    (1) Prophylactic antiepileptic drugs are not recommended (grade II recommendation, grade B evidence).

    (2) Authors with clinical epileptic disease should undergo antiepileptic drug therapy (Grade I recommendation, Grade A evidence).

    (3) Authors suspected of epileptic incidence should consider continuous EEG monitoring (grade II recommendation, grade B evidence); If a seizure discharge is detected, antiepileptic medications should be given (Grade I recommendation, Grade C evidence).

    ➤ Recommendations for the prevention and treatment
    of deep vein thrombosis (DVT) and pulmonary embolism:
    (1) Bedridden patients should pay attention to the prevention of DVT (Grade I recommendation, Grade C evidence); If the suspected patient can have D-dimer testing and limb Doppler ultrasonography (grade I recommendation, C grade evidence).

    (2) Encourage patients to move and raise their legs as soon as possible; As far as possible, avoid intravenous fluids from the lower extremities, particularly on the paralyzed side of the limb (grade IV recommendation, grade D evidence
    ).
    (3) The application of air pressure pump device after admission of paralyzed patients can prevent DVT and related embolic events (Grade I recommendation, Grade A evidence); Compression stockings for prophylaxis DVT (Grade I recommendation, Grade A evidence)
    is not recommended.
    (4) For high-risk patients prone to DVT (excluding cerebral hemorrhage caused by coagulation dysfunction), after hematoma stabilization, subcutaneous injection of low-molecular-weight heparin or unfractionated heparin 1 to 4 days after the onset of the disease can be considered to prevent DVT, but the risk of bleeding should be noted (grade II recommendation, grade B evidence).

    (5) When patients have symptoms of DVT or pulmonary artery embolism, systemic anticoagulation or inferior vena cava filter implantation can be used (Grade II recommendation, Grade C evidence); The choice of appropriate treatment depends on multiple factors (bleeding time, hematoma stability, cause of bleeding, and systemic conditions) (grade II recommendation, grade C evidence).

    Surgical treatment


    ➤ Cerebral parenchymal hemorrhage
    surgery has become an important method
    for the treatment of hypertensive cerebral hemorrhage with its advantages of rapid removal of hematoma, relief of cranial hypertension and release of mechanical compression.

    Recommendation: For most patients with primary intracerebral hemorrhage, the effectiveness of surgical craniotomy is not fully determined, and the indiscriminate routine use of surgical craniotomy (grade II recommendation, grade B evidence) is not advocated, and minimally invasive treatment is safe and helps reduce mortality (grade I recommendation, grade A evidence).

    Surgical craniotomy or minimally invasive surgical treatment can be considered individually in the following clinical conditions: (1) Patients with neurological deterioration or cerebral stem compression cerebellar hemorrhage, regardless of whether there is a manifestation of ventricular obstruction causing hydrocephalus, should be surgically removed as soon as possible (Grade I recommendation, Grade B evidence); Ventricular drainage alone without hematoma clearance is not recommended (grade II recommendation, grade C evidence).

    (2) For patients with lobular hemorrhage exceeding 30 ml and within 1 cm from the cortical surface, standard craniotomy can be considered to remove the supratentorial hematoma or minimally invasive surgery to remove the hematoma (grade II recommendation, grade B evidence).

    (3) Patients with supine hypertension cerebral hemorrhage within 72 hours of onset, hematoma volume of 20 to 40 ml, and GCS ≥ 9 points, in hospitals with conditions, can be cleared by minimally invasive surgery combined with or without thrombolytic drug liquefaction drainage after strict selection (grade II recommendation, grade A evidence).

    (4) Patients with severe cerebral hemorrhage of more than 40 ml whose consciousness disorder worsens due to the mass effect of hematoma, minimally invasive surgery to remove the hematoma (grade II recommendation, grade B evidence)
    may be considered.
    (5) Minimally invasive treatment should remove the hematoma as much as possible, so that the residual hematoma volume at the end of treatment ≤ 15 ml (grade II recommendation, grade B evidence).

    (6) Patients with unspecified cause of cerebral hemorrhage should undergo vascular-related examination (CTA/MRA/DSA) before minimally invasive surgery to exclude vascular lesions and avoid and reduce the risk of rebleeding (grade II recommendation, grade D evidence).

    ➤ Ventricular hemorrhage Recommendation: EVD combined with rt-PA in the treatment of ventricular hemorrhage is safe and helps to reduce the case fatality rate in severe patients (Grade I recommendation, Grade A evidence), and neurological function improvement needs to be further studied (Grade II recommendation, Grade A evidence); Combined lumbar puncture catheter drainage helps to accelerate the clearance of ventricular hemorrhage and reduce the risk of ventricular abdominal shunt (Grade II recommendation, Grade B evidence) Reference:[1] Neurology Branch of Chinese Medical Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association.
    Chinese Guidelines for the Diagnosis and Treatment of Cerebral Hemorrhage (2019)[J].
    Chinese Journal of Neurology,2019,52(12):994-1005.
    DOI:10.
    3760/cma.
    j.
    issn.
    1006-7876.
    2019.
    12.
    003.
    [2] China Stroke Prevention and Control Guidelines (2021 edition).


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    The source of this article Neural News Responsible Editor Mr.
    Lu Li

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