Hemorrhagic strokeHemorrhagic stroke

StrokeStroke

is acute disorders of cerebral circulation, is acute disorders of cerebral circulation, rapidly developing clinical signs of focal rapidly developing clinical signs of focal (at times global) disturbance of cerebral (at times global) disturbance of cerebral function, lasting more than 24 hours or function, lasting more than 24 hours or leading to death with no apparent cause leading to death with no apparent cause other then that of vascular originother then that of vascular origin

Hemorrhagic strokeHemorrhagic strokeIntracerebral (Intracerebral (when the hemorrhage is into the when the hemorrhage is into the substance or parenchyma of the brainsubstance or parenchyma of the brain ) )Membrane Membrane

– subarachnoid (when the bleeding originates in the subarachnoid (when the bleeding originates in the subarachnoid spaces surrounding the brain)subarachnoid spaces surrounding the brain)

– epidural and subduralepidural and subdural

Combined Combined – subarachnoid – parenchymatose subarachnoid – parenchymatose – parenchymatose– subarachnoidparenchymatose– subarachnoid– parenchymatose–ventricularparenchymatose–ventricular– ventricularventricular

The most common causes of The most common causes of hemorrhage are:hemorrhage are:

HypertensionHypertensionSymptomatic arterial hypertension (at Symptomatic arterial hypertension (at kidney diseases, systemic vessel kidney diseases, systemic vessel processes)processes)Inborn arterial and arterio – venous Inborn arterial and arterio – venous malformationsmalformationsBlood diseases (leucosis, polycythemia)Blood diseases (leucosis, polycythemia)Cerebral atherosclerosisCerebral atherosclerosisIntoxications, such as uremia, sepsisIntoxications, such as uremia, sepsis

AneurysmAneurysm

AneurysmAneurysm

According to the localization there are :According to the localization there are :Lateral hemorrhageLateral hemorrhage ( (they are located laterally they are located laterally

compared with the internal capsulecompared with the internal capsule))

Medial hemorrhageMedial hemorrhage (they are located (they are located medially compared with the internal capsule)medially compared with the internal capsule)

Combined hemorrhagesCombined hemorrhages (they take the (they take the

whole region of basal nuclei: subcortical nuclei, thalamus, whole region of basal nuclei: subcortical nuclei, thalamus, internal capsule)internal capsule)

Brain stem hemorrhagesBrain stem hemorrhages

Cerebellar hemorrhages Cerebellar hemorrhages

In hemisphereIn hemisphere

In ventriculesIn ventricules

PathomorphologyPathomorphology

Per rexisPer rexis

Per diapedesisPer diapedesis

The main periods of strokeThe main periods of stroke

Acute (up to 3 – 4 months)Acute (up to 3 – 4 months)

Renewal (up to 1 year)Renewal (up to 1 year)

Residual Residual

Stages of acute periodStages of acute period

Precursors Precursors

Apoplectic strokeApoplectic stroke

Focal signsFocal signs

General cerebral symptomsGeneral cerebral symptoms

severe headachesevere headachenauseanauseavomitingvomitingseizuresseizuresconsciousness disordersconsciousness disorders

- soporsopor- stuporstupor- semicomasemicoma- comacoma

ComaComais characterized by deep is characterized by deep

consciousness disorder, consciousness disorder, disturbance of breathing disturbance of breathing and heart activity. The and heart activity. The patient doesn’t respond to patient doesn’t respond to stimuli.stimuli.

C o m aC o m a

response to stimuli is absentresponse to stimuli is absenteyes are closed, mouth is opened eyes are closed, mouth is opened face is red, lips are cyanotic, skin is cold, face is red, lips are cyanotic, skin is cold, neck vessels are pulsing neck vessels are pulsing there is breathing disturbance there is breathing disturbance pulse is strained and slow pulse is strained and slow blood pressure is increased blood pressure is increased temperature increases in 24 hours temperature increases in 24 hours patient is lying on his back patient is lying on his back all muscles are relaxed all muscles are relaxed pupils are changed (there can be anizokoria, cross – pupils are changed (there can be anizokoria, cross – eyes, sometimes gaze paresis can be observed)eyes, sometimes gaze paresis can be observed)mouth angle is a little bit lower mouth angle is a little bit lower

On the opposite sideOn the opposite side

hemiplegia is often observed: hemiplegia is often observed:

the arm is falling down like binethe arm is falling down like bine

there is hypotonia of musclesthere is hypotonia of muscles

reflexes are low reflexes are low

Babinski sign is often observed Babinski sign is often observed tootoo

Large hemisphere hemorrhageLarge hemisphere hemorrhage

meningeal signs meningeal signs

vomiting and dysphagia vomiting and dysphagia

retention of urine or involuntary retention of urine or involuntary urination urination

in case of cortex irritation epileptic in case of cortex irritation epileptic attacks attacks

Sign of paralysis in right sideSign of paralysis in right side

Sign of central paralysisSign of central paralysis

Secondary brain stem syndromeSecondary brain stem syndrome

progressive breathing disordersprogressive breathing disorders

disturbance of heart activitydisturbance of heart activity

consciousness disordersconsciousness disorders

disturbance of eye movementsdisturbance of eye movements

changes of muscle tonus (hormetonia)changes of muscle tonus (hormetonia)

autonomic disorders (sweating, autonomic disorders (sweating, tachycardia, hyperthermia)tachycardia, hyperthermia)

Brain stem hemorrhageBrain stem hemorrhage

tetraparesistetraparesis

alternating syndromesalternating syndromes

eye movements disorderseye movements disorders

NystagmusNystagmus

gorge disordersgorge disorders

cerebellar syndromes.cerebellar syndromes.

Pons hemorrhagePons hemorrhage

ptosisptosis

gaze paresisgaze paresis

increased muscular tone increased muscular tone (hormetonia)(hormetonia)

Cerebellar hemorrhageCerebellar hemorrhage

DizzinessDizzinessSevere headache in occipital lobeSevere headache in occipital lobeVomitingVomitingEye movements disorders Eye movements disorders Ptosis Ptosis Gervig – Mazhandi syndrome, Parino syndrome Gervig – Mazhandi syndrome, Parino syndrome Cerebellar symptoms - nystagmus, dysartria, Cerebellar symptoms - nystagmus, dysartria, hypotonia, ataxiahypotonia, ataxiaParesis of extremities is not commonParesis of extremities is not common

Complication of intracerebral Complication of intracerebral hemorrhagehemorrhage

is is rupture into the ventricle systemrupture into the ventricle system. This . This is usually associated with: is usually associated with:

worsening of patient’s stateworsening of patient’s state

HyperthermiaHyperthermia

breathing disordersbreathing disorders

hormetonia hormetonia manifests as changes of muscle manifests as changes of muscle tone in extremities, when hypotonia is changed tone in extremities, when hypotonia is changed into hypertonia in a few seconds or minutes.into hypertonia in a few seconds or minutes.

DiagnosticsDiagnosticsIn In bloodblood usually leucocytosis, related usually leucocytosis, related lymphopenia, hyperglycemia (up to 8 – 10 mmole lymphopenia, hyperglycemia (up to 8 – 10 mmole per liter)per liter)In In liquorliquor high pressure during lubar puncture a high pressure during lubar puncture a great number of erythrocytes are found great number of erythrocytes are found On On eye funduseye fundus – retinal hemorrhages, hypertonic – retinal hemorrhages, hypertonic angioretinopathy and Salus symptoms are angioretinopathy and Salus symptoms are observed observed At At echoencephaloscopyechoencephaloscopy there is dislocation of there is dislocation of middle structures on 6 –7 sm to the healthy side middle structures on 6 –7 sm to the healthy side AtAt angiography angiography - aneurysm, dislocation of blood - aneurysm, dislocation of blood vessels, to find out zone “without vessels“vessels, to find out zone “without vessels“CTCT and and MRIMRI find out hyperdensive focuses. find out hyperdensive focuses.

In In liquorliquor high pressure during lubar puncture a high pressure during lubar puncture a

great number of erythrocytes are foundgreat number of erythrocytes are found 1. normal1. normal

2. subarachnoid 2. subarachnoid hemorrhagehemorrhage

3. intracerebral 3. intracerebral hemorrhagehemorrhage

4. xantochromia4. xantochromia

On On eye funduseye fundus – – retinal hemorrhages, retinal hemorrhages, hypertonic angioretinopathy and Salus symptoms are hypertonic angioretinopathy and Salus symptoms are

observedobserved 1-2 embolism of 1-2 embolism of retinal vesselsretinal vessels

3 – hypertensive 3 – hypertensive encephalopathyencephalopathy

4 – subarachnoid 4 – subarachnoid hemorrhage hemorrhage

At At echoencephaloscopyechoencephaloscopy

there is dislocation of there is dislocation of middle structures on 6 middle structures on 6 –7 sm to the healthy –7 sm to the healthy sideside

Differential diagnosis Differential diagnosis

Infarction of brain (thrombembolic)Infarction of brain (thrombembolic)

EpistatusEpistatus

Uremic comaUremic coma

Diabetic comaDiabetic coma

Traumatic hemorrhageTraumatic hemorrhage

Brain tumor with inside hemorrhageBrain tumor with inside hemorrhage

Subdural haematomaSubdural haematoma

Subdural haematomaSubdural haematoma

MRI. Intracerebral hemorrhigMRI. Intracerebral hemorrhig

Subarachnoid hemorrhageSubarachnoid hemorrhage

Aetiologic factors:Aetiologic factors:Aneurysmatic ( 50 – 62 % ) – aneurysm rupture.Aneurysmatic ( 50 – 62 % ) – aneurysm rupture.Hypertensive ( at hypertension )Hypertensive ( at hypertension )Atherosclerotic ( 15 % )Atherosclerotic ( 15 % )Traumatic ( 5 – 6 % )Traumatic ( 5 – 6 % )Infectious – toxic ( 8.5 % )Infectious – toxic ( 8.5 % )Blastomatose ( at tumors )Blastomatose ( at tumors )Pathohemic ( at blood diseases )Pathohemic ( at blood diseases )Cryptogenic ( 4 – 4.8 % )Cryptogenic ( 4 – 4.8 % )

Clinical featuresClinical features

Severe headacheSevere headache or feeling of hot liquid flowing or feeling of hot liquid flowing in the brain (pain is local in the region of occipital in the brain (pain is local in the region of occipital lobe). Later pains in neck, back appear, lobe). Later pains in neck, back appear, sometimes they irradiate in legs. sometimes they irradiate in legs.

Simultaneously with headache Simultaneously with headache vomiting and vomiting and nauseanausea occur. occur.

there are other there are other general cerebral symptomsgeneral cerebral symptoms:: short loss of consciousness, psychomotor short loss of consciousness, psychomotor excitement, seizures. excitement, seizures.

Subarachnoid hemorrhigSubarachnoid hemorrhig

Subarachnoid hemorrhigSubarachnoid hemorrhig

Clinical featuresClinical features

Meningeal syndromeMeningeal syndrome rigidity of occipital musclesrigidity of occipital musclessymptoms of Kernig, Brudzinskysymptoms of Kernig, Brudzinskygeneral hyperesthesia. general hyperesthesia.

Significant Significant focal neurologic symptoms are not focal neurologic symptoms are not common.common. Only in case of basal hemorrhage CNs Only in case of basal hemorrhage CNs suffer (that is the reason of ptosis, cross – eye, suffer (that is the reason of ptosis, cross – eye, dyplopia, paresis of mimic muscles). That’s why dyplopia, paresis of mimic muscles). That’s why lesion of CNs is typical for basal aneurysm lesion of CNs is typical for basal aneurysm rupture.rupture.

Kernig’s signKernig’s sign

Complications Complications

Brain edemaBrain edema

Recurrent SHRecurrent SH

Occlusive hydrocephaliaOcclusive hydrocephalia

Brain infarction Brain infarction

DiagnosisDiagnosis

Stroke – like development with general Stroke – like development with general cerebral and meningeal symptoms and cerebral and meningeal symptoms and absence of significant focal neurologic absence of significant focal neurologic deficitdeficit

The presence of blood in liquor (bleeding The presence of blood in liquor (bleeding liquor during first day and yellow liquor on liquor during first day and yellow liquor on 3rd – 5th day)3rd – 5th day)

Retinal hemorrhages are on eye fundusRetinal hemorrhages are on eye fundus

Differential diagnosisDifferential diagnosis

MeningitisMeningitis

Acute food toxic infectionAcute food toxic infection

Infectious diseasesInfectious diseases

Strokes treatmentStrokes treatmentNondifferential treatmentNondifferential treatment includes:includes:

Prevention and treatment of pulmonary Prevention and treatment of pulmonary insufficiency insufficiency Liquidation of heart – vascular disordersLiquidation of heart – vascular disordersBrain edema treatmentBrain edema treatmentNormalization of water – electrolytes balance Normalization of water – electrolytes balance and acid – alkali balanceand acid – alkali balanceOsmosis correctionOsmosis correctionImproving of brain metabolismImproving of brain metabolismLiquidation of hyperthermia and other Liquidation of hyperthermia and other autonomic disordersautonomic disorders

Liquidation of heart – vascular Liquidation of heart – vascular disordersdisorders

At increased blood pressure we useAt increased blood pressure we useClofelini 1 – 3 ml 0.01 % solution i/m, i/v.Clofelini 1 – 3 ml 0.01 % solution i/m, i/v.Dibasoli 3 – 4 ml 1 % solution i/vDibasoli 3 – 4 ml 1 % solution i/vDroperidoli 1 ml 0.25 % solution i/vDroperidoli 1 ml 0.25 % solution i/vRasedili 1 – 2 ml 0.1 % i/v, I / m, Rasedili 1 – 2 ml 0.1 % i/v, I / m, - adrenoblockers ( anaprilini, obzidani, inderali )- adrenoblockers ( anaprilini, obzidani, inderali )peripheral vasodilatators ( Natrii nytroprussidi , peripheral vasodilatators ( Natrii nytroprussidi , appresini ) in combination with euphylliniappresini ) in combination with euphyllini

At low blood pressure we prescribeAt low blood pressure we prescribeDexamethazoni 4 – 8 mg i/v by drops in physiological solutionDexamethazoni 4 – 8 mg i/v by drops in physiological solutionPrednizoloni 60 – 120 mg i/v by drops in physiological Prednizoloni 60 – 120 mg i/v by drops in physiological solutionsolutionIn order to improve heart activity we use strofantini, In order to improve heart activity we use strofantini, corgliconi, cordiaminicorgliconi, cordiamini

Brain edema treatmentBrain edema treatment

DiureticsDiureticsCorticosteroidsCorticosteroidsAlbuminiAlbuminiGanglioblockersGanglioblockers20 % mannit20 % mannitManitoliManitoliGlyceriniGlyceriniLazixLazixDiakarbiDiakarbi

Differential treatment of Differential treatment of hemorrhagehemorrhage

The main directions of treatment are:The main directions of treatment are:– To lower increased blood pressureTo lower increased blood pressure– To liquidate brain edema and lower intracranial To liquidate brain edema and lower intracranial

pressurepressure– To increase coagulative properties of blood and To increase coagulative properties of blood and

decrease penetrance of vessels’ walldecrease penetrance of vessels’ wall– To prevent and treat cerebral vessels spasmTo prevent and treat cerebral vessels spasm– To normalize vital and autonomic functions and To normalize vital and autonomic functions and

prevent complicationsprevent complications– To treat hypoxia and brain metabolism disordersTo treat hypoxia and brain metabolism disorders