Therapy of a cerebral hemorrhage
How can a cerebral haemorrhage be treated?
It is important to react early to the symptoms of a cerebral haemorrhage and to initiate therapy quickly after imaging of a cerebral haemorrhage in order to prevent secondary bleeding in the first 24 hours, which occurs in more than a third of patients if left untreated, and consequential damage, e.g. by reducing the to minimize increased intracranial pressure.
A basic distinction is made between conservative and surgical measures and rehabilitative follow-up treatments.
As part of conservative therapy, attempts are first made to prevent the bleeding from expanding and an increase in intracranial pressure, which correlates with the cerebral blood flow.
Many of the patients require intensive care. In addition to monitoring the vital body functions (vital parameters), e.g. pulse, blood pressure and temperature, for severely impaired patients, to maintain the oxygen supply, artificial ventilation with the help of a ventilator inserted into the airways (Intubation).
Read more on the topic: What are the chances of recovery after a cerebral hemorrhage?
Patients whose condition is critical must be on one Intensive care unit are monitored while awake patients are on a ward specialized in stroke care (Stroke Unit) can be supplied.
In the first hours to days after the ICB If the blood pressure is too high in the patient, it should be adjusted with medication, but it should be noted that if the blood pressure is lowered too quickly and too much, the nerve tissue around the bleeding focus may be insufficiently supplied and thus additional brain damage is threatened.
Used to lower blood pressure are most common Urapidil and Clonidine (Catapressan) used. Urapidil is mainly used for acute increases in blood pressure. It blocks alpha 1 vascular receptors in the periphery, which leads to a decrease in vascular resistance and thus lowers blood pressure.
It also works via central serotonin receptors and thus suppresses a counter-regulation that is normally triggered by the sympathetic nervous system. This usually causes a backlash on the Heart in the sense of an increased Heart rate (Tachycardia) and an increase in the beating power of the heart (Contractility). Urapidil is used in the Therapy of high blood pressure (arterial hypertension) used. Side effects can include nausea, headache and dizziness. Urapidil is also used in emergency medicine.
Clonidine acts on alpha 2 receptors in the central nervous system and subsequently reduces the release of norepinephrine, a Neurotransmitters, the part of the sympathetic nervous system. This in turn reduces the heart rate (Bradycardia) and blood pressure lowered (Hypotension).
Initial ingestion may lead to an increase in blood pressure (high blood pressure), as clonidine also has a non-specific effect on other receptors. The side effects include the typical symptoms that occur when the sympathetic nervous system is slowed down, including dry mouth, sluggish stomach and intestines, constipation (Constipation), Tiredness and drowsiness.
Clonidine is enhanced in its mode of action by various substances. These include, for example, alcohol and Antidepressants.
The treatment of coagulation disorders, which have already been mentioned as risk factors, is also important. One option is substitution therapy, i.e. the replacement of missing coagulation factors. Protamine sulfate can be administered as an antidote to cerebral hemorrhage during heparin treatment. Often there is the therapeutic dilemma that patients who have been on anticoagulant therapy for many years cannot suddenly stop it, but continue to rely on the therapy, for example due to artificial heart valves and the resulting increased risk of blood clots being deposited.
Vascular malformations in the brain, for example cavernomas, which are responsible for ICB, must be corrected early on in order to rule out repeated bleeding.
Since epileptic seizures can occur in around 10% of those affected with large intracerebral hemorrhages, antiepileptic drugs are administered prophylactically or when a seizure occurs.
The blood sugar should be kept in the normal range and an increase (Hyperglycemia) be avoided.
If those with nerve water (Cerebrospinal fluid), filled spaces of the brain (Ventricle) increasingly expand, an artificial drain (drainage) are applied to lower the pressure and thus prevent mass displacement of the brain and entrapment.
There are studies examining an as yet unapproved drug, recombinant factor 7a, which, in initial studies, could reduce the rate of rebleeding when given within the first few hours after the bleeding.
Depending on the position and size of the bleeding, as well as the age and level of consciousness of the patient, bleeding can also be removed surgically.
Surgery is particularly suitable for bleeding in the brainstem area, where there is a risk of entrapment of the vital centers for breathing and circulation. However, there is little information on the advantages and disadvantages of surgery compared to conservative therapy for intracerebral bleeding. For this reason, the risk-benefit ratio of a surgical procedure has to be decided for the individual.
For more information read also: Operation of a cerebral haemorrhage , What are the causes of a cerebral hemorrhage
Subsequent to early therapy measures are:
- Speech therapy and
- Occupational therapy
important depending on the failure pattern, as is the treatment of risk factors and causes of bleeding.
When do you need an operation?
Basically, not all patients with an existing cerebral hemorrhage benefit from surgical therapy. It is therefore important to carefully consider whether this patient is indicated for surgery or not. In most cases, bleeding is only considered worthy of surgery if it leads to a neurological disorder. This assumes that so much blood has flowed into the skull that certain areas of the brain are now pushed away and can no longer perform their actual function. One then speaks of a symptomatic cerebral hemorrhage. Furthermore, a distinction has to be made here between the exact location of the bleeding, since surgical evacuation of the blood is only possible if the cause of the bleeding is as superficial as possible or directly in the cerebellum.
Read more on the topic: Operation of a cerebral haemorrhage
Duration of the operation
It is difficult to describe an exact time frame for the operation of a cerebral haemorrhage, as this depends on various factors. In addition to the location and extent of the bleeding, this also includes other circumstances, such as the surgeon's experience or any complications. As a rule, however, one can speak of a general duration between two and eight hours. In individual cases, however, the duration of the operation can differ greatly from this information.
Risks of the operation
Since the surgical treatment of a cerebral hemorrhage is almost always associated with the opening of the skull bone, such an operation is of course also associated with certain risks. On the one hand, with brain operations there is always the possibility that certain brain regions will be damaged during the operation and possibly result in functional failures. However, such a complication is comparatively very rare. Furthermore, it is possible that patients have an epileptic seizure during the procedure, but this can be treated well and quickly. There is also the risk of postoperative bleeding if not all vessels have been adequately supplied or injured during the operation.
Read more on the topic: Postoperative Complications - What Are There ?, Postoperative Pain
How does an operation work for a cerebral hemorrhage?
In almost all cases, surgical treatment of a cerebral hemorrhage starts with the opening of the skull, the so-called. Craniotomy, hand in hand. To do this, the hair in the operating area is first shaved off. Now, under general anesthesia of course, the skin in this area is carefully detached from the skull bone and folded aside. Now the actual opening of the skull takes place by opening the skull bone with a suitable saw. This is followed by the evacuation of the blood and the supply of the injured vessel. As soon as the surgeon is sure that all vessels are well supplied, the skull is closed again. The cut-out bone plate is either anchored to the rest of the skull via plates or wires and the skin is sewn on. In most cases, after the hair regrowth, nothing can be seen from the operation.