Cerebral hemorrhage

Cerebral hemorrhage in the brain may be intracerebral, subarachnoid or intraventricular. The commonest cause of an intracerebral hemorrhage is rupture of an atheromatous artery in a person suffering from hypertension which in most of the cases is uncontrolled. Factor of degeneration of the cerebral blood vessels along with fluctuations of blood pressure levels account for most of the cases.

Most of the cases suffering from cerebral hemorrhage are either in elderly age group or late middle age. Young persons do not commonly suffer from it.

Cerebral hemorrhage may occur at any site though internal capsule is the commonest site. Other sites are lateral ventricle and sub arachnoid space. Once hemorrhage takes place that part of the brain gets swollen and oedematous. The gyri are flattened. Mid brain is displaced to the side opposite the hemorrhage. Cerebral ventricles get distorted. As the site of hemorrhage is occupied by a clot it may get absorbed later on and is replaced by a scar tissue.

Cerebral hemorrhage

Symptoms

A known case of hypertension complains of severe headache accompanied by nausea, vomiting There may be premonitory symptoms in the form of transient speech disturbances or weakness of limbs. Once hemorrhage occurs patient become unconscious over a very short period.

In addition to general picture of an unconscious patient signs in a patient of cerebral hemorrhage shall depend on the site of the lesion.

1. In the region of internal capsule. Patient is unconscious and its depth depends on the degree of hemorrhage. Pulse is slow, and breathing is Cheyne-Stokes type. Neck rigidity is present. Head is rotated and eyes are deviated towards the side of lesion. Pupils are often unequal though they react to light. Papilloedema is present. There is flattening of nasolabial folds of face and absence of movements on the paralyzed limb. Retention or incontinence of urine may be present.

2. Pontine hemorrhage. In early stages there is facial paralysis on the side of the lesion with flaccid paralysis of limbs on the opposite side. There is paralysis of conjugate deviation of eyes, head and eyes of the patient are turned towards the paralyzed side. With extension hemorrhage involves the whole pons and now signs include paralysis of face and the limbs. Pupils are contracted and pin pointed. Because of involvement of heat regulating center, temperature levels rise. Patient is generally deeply comatose, respiration is either Cheyne-Stokes or labored.

3. Hemorrhage into the ventricles. When hemorrhage extends into the ventricles, level of unconsciousness further deepens. There may be signs of pyramidal tract involvement which are usually bilateral. Temperature is raised. Hyperpyrexia may be seen terminally.

Diagnosis. Clinical picture of sudden unconsciousness preceded by severe headache, nausea and vomiting in a hypertensive patient should make one suspect it. CSF shows raised pressure. It is hemorrhagic, protein content is markedly raised. CSF sugar and chloride levels are normal. Cell count of CSF shows innumerable RBCs. CT scan skull is the most important diagnostic aid to locate the site of cerebral hemorrhage.

1. Patient should be put to complete bed rest and nursed with as little disturbance as possible. Maintain nutrition, hydration and electrolyte balance. Care of the bowel and bladder, keep respiratory passage cleat

2. For raised intracranial pressure Injection Dexamethasone 4 mg IN 6 hourly in the acute stage.

3. Epsilon amino caproic acid (EACA). It is an analogue of amino acid lysine and is effective in cases of intravascular bleeding. Drug is to be given slowly intravenously in drip (5 g/20 ml). Rapid injection may result in hypo tension, bradycardia and arrhythmias.

4. Use of antibiotics (Injection Ampicillin 500 mg IN 6 hourly) to prevent any secondary infection).

5. Hypertension must be controlled since high levels of blood pressure shall further aggravate the condition. But rapid lowering of blood pressure is also not desirable. Usually injection Serpasil 1 mg i/rn stat is given and further dosage adjusted according to blood pressure levels.

A case of cerebral hemorrhage requires great care in nursing. There should be no untoward disturbance of the patient so as to prevent further bleeding.

Prognosis in a case of cerebral hemorrhage is not good. Even after recovery chances of re-bleed are there.

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