A Comprehensive Guide to the Diagnosis and Treatment of Hemorrhagic Cerebrovascular Diseases: From Cerebral Hemorrhage and Subarachnoid Hemorrhage to Perioperative Management

Intracerebral hemorrhage. Intracerebral hemorrhage is bleeding within the brain parenchyma (excluding those caused by trauma). The incidence rate is 60-80 per 100,000 population per year, accounting for approximately 30% of acute cerebrovascular diseases in my country. The acute-phase mortality rate is 30%-40%. Of those cases, hemispheric hemorrhage accounts for about 80%, while brainstem and cerebellar hemorrhage account for about 20%. Brain CT scan is the most effective and rapid method for diagnosing intracerebral hemorrhage. Treatment for intracerebral hemorrhage primarily involves timely removal of the hematoma, aggressive reduction of intracranial pressure, and protection of the brain tissue surrounding the hematoma. Hypertension is the most significant contributing factor.

(I) Diagnostic points. 1. Clinical characteristics. (1) Acute onset under dynamic conditions; (2) Sudden onset of focal neurological deficits, often accompanied by headache, vomiting, and may be accompanied by high blood pressure, altered consciousness and meningeal irritation signs. 2. Auxiliary examinations. (1) Blood tests: may show leukocytosis, elevated blood sugar, etc.; (2) Imaging examinations: ● Head CT scan: is a safe and effective method for diagnosing cerebral hemorrhage. It can accurately and clearly show the location, amount of bleeding, mass effect, whether it has ruptured into the ventricle or subarachnoid space and the damage to surrounding brain tissue. CT scans of cerebral hemorrhage show hematoma foci as high-density shadows with clear boundaries. ● Head MRI examination: is not the first-line diagnostic method. However, MRI examination can more accurately show the evolution of hematoma and may be helpful in exploring the etiology of some patients with cerebral hemorrhage. ● Cerebral angiography (DSA): Cerebral angiography should be performed in young and middle-aged non-hypertensive cerebral hemorrhage, or when CT and MRI examinations suspect vascular abnormalities. (3) Lumbar puncture: In cases where CT scans are not available or cannot be performed, lumbar puncture can be used to assist in the diagnosis of cerebral hemorrhage, but the positive rate is only about 60%. For massive cerebral hemorrhage, especially in the early stage of brain herniation, lumbar puncture should be performed with extreme caution and is now rarely performed.

(II) Key Points of Treatment. 1. Medical Treatment. (1) General Treatment. Bed rest; maintain airway patency; oxygen inhalation; nasogastric feeding: for comatose patients or those with difficulty swallowing; symptomatic treatment; infection prevention; observation of the condition: closely monitor changes in the patient's consciousness, pupil size, blood pressure, respiration, etc. (2) Blood Pressure Control. There is no fixed standard for controlling blood pressure in patients with cerebral hemorrhage. It should be determined based on the patient's age, history of hypertension, presence of intracranial pressure, cause of hemorrhage, onset time, etc. Generally, the following principles can be followed: patients with cerebral hemorrhage should not rush to lower blood pressure, because the increase in blood pressure after cerebral hemorrhage is a reflexive self-regulation of increased intracranial pressure. Intracranial pressure should be lowered first, and then the decision on whether to carry out blood pressure lowering treatment should be made based on the blood pressure situation; when blood pressure is ≥200/110 mmHg, blood pressure lowering treatment can be carried out cautiously and steadily while lowering intracranial pressure, so that blood pressure is maintained at a level slightly higher than the pre-onset level or around 180/105 mmHg. If the systolic blood pressure is between 170 and 200 mmHg or the diastolic blood pressure is between 100 and 110 mmHg, antihypertensive drugs may not be necessary for the time being; dehydration and intracranial pressure reduction should be prioritized. If the systolic blood pressure is <165 mmHg or the diastolic blood pressure is <95 mmHg, antihypertensive treatment is not necessary. Patients with excessively low blood pressure should receive vasopressor treatment to maintain cerebral perfusion pressure. During the recovery period, blood pressure should be actively reduced, and stratified treatment should be implemented based on other risk factors. (3) Reduce intracranial pressure. Increased intracranial pressure is the main cause of death in patients with cerebral hemorrhage. Treatment for reducing intracranial pressure in patients with cerebral hemorrhage primarily involves hypertonic dehydrating agents, such as mannitol or glycerol fructose, glycerol sodium chloride, etc., while paying attention to urine output, serum potassium, and cardiac and renal function. Furosemide (Lasix) and albumin may be used as appropriate. It is recommended to avoid the use of steroids as much as possible due to their significant side effects. (4) Hemostatic drugs. Generally not used, but may be used if there is coagulation dysfunction. (5) Hypothermia therapy. Hypothermia is an adjunct treatment for cerebral hemorrhage, and units with the necessary conditions can try it. (6) Rehabilitation treatment. In the early stage, the affected limb should be placed in a functional position. If the condition allows, rehabilitation treatment should be carried out as soon as possible after the danger period. 2. Surgical treatment. The purpose of surgery is mainly to remove the hematoma as soon as possible, reduce intracranial pressure, and save lives. The Chinese Guidelines for the Prevention and Treatment of Cerebrovascular Diseases recommend: (1) If middle-aged and elderly patients with a history of hypertension suddenly develop focal neurological deficit symptoms, accompanied by headache, vomiting, and increased blood pressure, cerebral hemorrhage should be considered. Head CT scan is the first choice. (2) The treatment plan should be determined according to the location and amount of bleeding: ● Basal ganglia hemorrhage: Moderate bleeding (putaminal hemorrhage ≥30ml, thalamic hemorrhage ≥15ml) can be performed at an appropriate time according to the condition, with minimally invasive puncture hematoma evacuation or small craniotomy for hematoma evacuation. ● Cerebellar hemorrhage: It is easy to form brain herniation. If the bleeding volume is ≥10ml, or the diameter is ≥3cm, or there is significant hydrocephalus, surgical treatment should be performed as soon as possible. ● Lobar hemorrhage: Except for large hematomas that endanger life or are caused by vascular malformations requiring surgical treatment, conservative medical treatment is recommended. ● Intraventricular hemorrhage: Severe intraventricular hemorrhage (ventricular cast) requires ventricular puncture and drainage plus lumbar puncture for fluid drainage. (3) Medical treatment is the basic treatment for cerebral hemorrhage. Dehydration to reduce intracranial pressure, blood pressure regulation, and prevention and treatment of complications are the central links in the treatment.

Subarachnoid hemorrhage. Primary subarachnoid hemorrhage (SAH) refers to the rupture of blood vessels on the surface of the brain, causing blood to flow into the subarachnoid space. The annual incidence rate is 5-20 per 100,000, accounting for 6%-8% of strokes. The most common cause is intracranial aneurysm, followed by cerebral vascular malformation.

(I) Diagnostic points. 1. Clinical characteristics. The clinical manifestations of subarachnoid hemorrhage mainly depend on the amount of bleeding, the location of blood accumulation, and the degree of damage to cerebrospinal fluid circulation. (1) Onset. It often occurs suddenly under conditions of emotional excitement or exertion. (2) Main symptoms. Sudden onset of severe headache that is persistent and cannot be relieved or progressively worsens; often accompanied by nausea and vomiting; there may be transient loss of consciousness and mental symptoms such as irritability and delirium. (3) Main signs. Meningeal irritation signs are obvious (neck stiffness), fundus hemorrhage can be seen, and a few may have signs of focal neurological deficits. 2. Auxiliary examinations. (1) Head CT. It is the preferred method for diagnosing SAH. A high-density shadow in the subarachnoid space on CT can confirm SAH. (2) Cerebrospinal fluid (CSF) examination. Usually, for those who have been diagnosed by CT examination, lumbar puncture is not used as a routine clinical examination. (3) Cerebrovascular imaging examination. It helps to detect abnormal blood vessels in the brain. These include cerebral angiography (DSA); CT angiography (CTA) and MR angiography (MRA); and transcranial Doppler ultrasound (TCD).

(II) Key points of treatment. 1. General management and symptomatic treatment. (1) Maintain stable vital signs; (2) Reduce intracranial pressure; (3) Correct water and electrolyte imbalance; (4) Strengthen nursing care. 2. Prevention and treatment of rebleeding. Rebleeding usually occurs within 1 month. (1) Quiet rest: Absolute bed rest for 4-6 weeks, avoid moving. (2) Blood pressure regulation: If blood pressure is too high, keep blood pressure below 180/100 mmHg and avoid excessive blood pressure reduction. (3) Surgical operation: For aneurysmal SAH, when Hunt and Hess grades are ≤ III, early surgical clipping of aneurysm or interventional embolization is often performed. 3. Prevention and treatment of cerebral arterial spasm and cerebral ischemia. About 1/4 of patients experience cerebral arterial spasm and cerebral ischemia, which peaks in 3-10 days. The key is prevention. (1) Maintain normal blood pressure and blood volume; (2) Use nimodipine early; (3) Lumbar puncture for CSF or CSF replacement. 4. Prevention and treatment of hydrocephalus. (1) Drug therapy: Mannitol, furosemide, etc. may be selected as appropriate; (2) CSF external drainage by ventricular puncture; (3) CSF shunt: If medical treatment for chronic hydrocephalus is ineffective, CSF shunt should be performed in time. 5. Management of diseased blood vessels. Interventional occlusion treatment does not require craniotomy and general anesthesia and has little impact on circulation. Surgical treatment requires comprehensive consideration of the complexity of aneurysm, etc. 6. Chinese guidelines for the prevention and treatment of cerebrovascular diseases recommend: (1) In medical units with the necessary conditions, SAH patients should be first diagnosed by neurosurgeons; (2) Cranial CT is the first choice for diagnostic examination; (3) If the clinical manifestations are typical and there are no signs of bleeding on CT, lumbar puncture can be performed with caution; (4) Active medical treatment helps stabilize the condition and restore function. To prevent rebleeding, antifibrinolytic drugs and calcium channel blockers can be used in combination.

Pre-hospital management of stroke. (I) Every second counts. Whether a stroke patient can be transported to the hospital promptly after onset is crucial for achieving the best treatment outcome and functional rehabilitation. Thrombolytic therapy is very effective for ischemic stroke, but the optimal treatment window is very short (3-6 hours). The public should have basic knowledge of recognizing stroke symptoms and transport patients to a qualified medical institution as quickly as possible. (II) Recognition of stroke. Common manifestations of stroke include: ● Sudden onset of symptoms; ● Weakness, clumsiness, heaviness, or numbness on one side of the body; ● Numbness on one side of the face or drooping of the mouth; ● Slurred speech or difficulty understanding language; ● Gazing to one side; ● Loss of vision or blurred vision in one or both eyes; ● Feeling of spinning, unsteadiness while standing or walking; ● Severe headache or vomiting that is unusual for the patient; ● Altered consciousness or seizures, or sudden confusion or coma. (III) First aid measures and related treatment for the patient. Remain calm and take the following appropriate measures: ● Call 120 immediately. ● Comfort the patient and remain calm. ● Allow the patient to rest and sleep quietly. Never call or shake the patient. ● Keep the airway open, loosen the patient's collar, and remove dentures if present. ● Position unconscious patients on their side. Maintain a steady speed during transport.

Cooperate with doctors in emergency diagnosis and treatment. (I) Diagnostic points. Clinical history is still an important basis for diagnosis. Typical cases are sudden onset and rapidly progressing signs of brain damage. (II) Treatment points. 1. Basic life support. (1) Airway and breathing. Ensure the patient's airway is open: if there is obvious respiratory distress or suffocation, endotracheal intubation or mechanical ventilation can be used. Administer oxygen to those with hypoxia. (2) Cardiac function. Perform routine electrocardiogram. If there is severe arrhythmia, heart failure or myocardial ischemia, it should be treated in time. (3) Timely treatment of emergencies, such as severe intracranial hypertension, gastrointestinal bleeding, epilepsy, high blood pressure, fever, etc.

Major complications of stroke. (I) Increased intracranial pressure. Increased intracranial pressure (ICP) is a common complication of acute stroke and one of the main causes of death in stroke patients. The purpose of treatment is to reduce intracranial pressure and prevent brain herniation. 1. General treatment. (1) Keep quiet and absolutely bedridden; (2) Control factors that cause increased ICP, such as excitement, exertion, fever, etc. 2. Dehydration treatment. Mannitol or glycerol fructose are the most commonly used dehydrating agents. Furosemide (Lasix) is generally administered intravenously at a dose of 20-40 mg every 6-8 hours. 3. Surgical treatment. Some severe patients require surgical treatment. (II) Changes in blood glucose. Active treatment of hyperglycemia plays an important role in the prognosis of acute cerebrovascular disease. When a patient's blood glucose level exceeds 11.1 mmol/L, insulin treatment should be given immediately to control blood glucose below 8.3 mmol/L. Hypoglycemia in acute stroke patients can worsen their condition and should be corrected with 10%–20% glucose. (III) Dysphagia. Dysphagia is more common in stroke patients with more severe conditions. The main goal of treatment is to prevent aspiration pneumonia. Within 48 hours of admission, patients should be monitored by specialists using effective nutritional monitoring methods. Dysphagia following a stroke usually resolves relatively quickly. If the patient is not at risk of nutritional deficiencies, nasogastric feeding is unnecessary for the first 5–7 days after the onset of the illness. If the patient is nutritionally deficient, nasogastric feeding can be initiated earlier. Because drinking water through a straw requires more complex oral muscle function, patients with dysphagia should not use straws. If drinking from a cup, the cup should be at least half full. Patients should sit up when eating, and generally consume soft, pureed, or jelly-like viscous foods, placing the food at the base of the tongue to facilitate swallowing. After eating, patients should remain in a sitting position for at least 0.5–1 hour.