Hemorrhagic insult I61.0-9

A hemorrhagic insult is an acute onset of neurological deficit caused by an acute onset of intracranial hemorrhage (Linn 2011).

The insults include:

- Primary hemorrhagic insult

- Ischemic insult (Herold 2022)

- Hemorrhagic cerebral infarction: This is a primary ischemic cerebral infarction in which diapedesis hemorrhage occurs due to increased capillary permeability caused by ischemia (Linn 2011).

The incidence of apoplexy in Germany is around 300 / 100,000 inhabitants / year between the ages of 55 - 64 and 800 / 100,000 inhabitants / year between the ages of 65 - 74. Men are more frequently affected than women (Herold 2022). However, hemorrhagic insult - caused by increased alcohol consumption - shows no gender differences (Patra 2010).

The hemorrhagic insult causes approx. 20% of all insults (Herold 2022).

Primary (spontaneous) intracerebral hemorrhage:

The main risk factor for a hemorrhagic insult is arterial hyper tension. Hypertension leads to a rupture of the vessels at a typical location, the so-called loco topico, e.g. in the area of the pons or in the subcortical medullary layer (Herold 2022).

Secondary intracerebral hemorrhage:

This is characterized by e.g. amyloid angiopathies, ingestion of anticoagulants, coagulation disorders, superficial siderosis, vasculitis, vascular malformations (Herold 2022), hemorrhagic diathesis, tumor hemorrhage, congestive hemorrhage as a result of venous thrombosis, traumatic (Diener 2004)

Alcohol abuse

A meta-analysis by Patra et al. from 2010 shows a linear increase in the risk of a hemorrhagic insult with increasing alcohol consumption. Alcohol consumption is also a major risk factor for high blood pressure (Patra 2010).

An acute hemorrhage in the brain causes an increase in intracranial pressure (ICP = intracerebral pressure) due to the bony skull. The compensatory reserve volume in an acute intracranial mass is between 30 - 50 ml. In addition, an increase in intracranial pressure leads to the suspension of cerebral autoregulation (Linn 2011).

Clinically, it is NOT possible to differentiate between a hemorrhagic or ischemic insult (Diener 2004). The symptoms themselves depend on the localization of the insult and can be:

- Sudden weakness of an arm, leg or face

- Motor aphasia

- Sensory aphasia

- Dysarthria

- Visual disturbances such as unilateral blindness, visual field loss, double vision (Linn 2011), nystagmus (Lehmeyer 2022)

- Balance disorders

- dizziness

- Headaches (Linn 2011)

- Nausea, vomiting (Lehmeyer 2022)

- Disturbance of consciousness (Linn 2011)

- Coma (Lehmeyer 2022)

A focused neurological examination should be carried out. This includes symptoms that indicate an apoplexy. They are summarized under the mnemonic FAST:

- Face: one-sided paralysis of the face

- Arm: Restriction of arm movement

- Speech: abnormalities in speech and / or speech comprehension

- Time: no time to lose, time is brain (Peter 2021).

An extension of this formula is the BE-FAST formula, which also checks:

- Balance: balance disorders

- Eye: disorders of eye movements or visual disturbances (Amboss SOP 2023)

Before therapeutic measures can be initiated, a cCT should be performed immediately to confirm the diagnosis.

cCT

Cranial CT generally shows cerebral hemorrhages well. In the case of cerebral ischemia symptoms, however, the infarct lesion can only be visualized in up to approx. 30 % (Lehmeyer 2022).

In the case of a hemorrhagic insult, bleeding into the brain parenchyma can be detected. In the case of subarachnoid hemorrhage, however, the hemorrhage affects the subarachnoid space filled with cerebrospinal fluid (Amboss SOP 2023).

cMRI

Although cMRI is significantly more sensitive when it comes to imaging apoplexy (especially ischemic insult), it is not always available 24 h / h and is more time-consuming and costly (Lehmeyer 2022).

- Ischemic insult (Herold 2022)

- TIA (transient ischemic attack), in which the same symptoms are present, but no lesion is found in the cMRI. The duration of symptoms of < 1 h previously used for diagnosis is no longer a criterion today (Lehmeyer 2022)

- Arterial hypertension

In the acute phase of an apoplexy - regardless of whether it is a hemorrhagic or ischemic insult - over 70 % of patients have hypertensive blood pressure values, as the autoregulation of cerebral blood flow may be suspended in the areas of the developing infarct. Severe fluctuations in blood pressure must be avoided at all costs, especially in this early phase. For more information on therapy, see "Internal therapy" (Schwab 2015).

Every case of suspected apoplexy should be immediately hospitalized (preferably in a clinic with a stroke unit). The immediate measures consist of:

- elevation of the upper body

- Establishment of a peripheral venous access (primarily on the unaffected side)

- Administration of 500 - 1,000 ml isotonic solution

- Blood pressure measurement: lowering of the RR only from values of > 220 /120 mmHg (for more details see "Internal therapy")

- Supply with. O2

- Securing the airways (Lehmeyer 2022)

Heparin, ASA, steroids and i.m. injections are contraindicated until bleeding has been ruled out by a cCT (Lehmeyer 2022).

If an intracerebral hemorrhage is detected on a CCT, specific treatment is given depending on the type of hemorrhage (Amboss SOP 2023). See also "Internal therapy".

Increasing intracranial pressure

If there is an increase in intracranial pressure, in addition to elevation of the upper body, medication such as mannitol or surgical measures such as external ventricular drainage or, in individual cases, hematoma evacuation are recommended (Lehmeyer 2022).

Hypertension

In the case of hypertensive blood pressure values, which can occur particularly in the early phase of an insult (see also "Complications"), large fluctuations in blood pressure should be avoided at all costs.

For patients with known arterial hypertension, the following guideline values are described: systolic 180 mmHg, diastolic 100 - 105 mmHg.

Patients without a history of hypertension should be set to lower values: systolic 160 - 180 mmHg and diastolic 90 - 100 mmHg.

Clonidine and Urapidil are particularly recommended as drugs to lower the hypertensive values. Alternatively, an easily controllable beta-blocker such as esmolol or metoprolol can also be used (Schwab 2015).

Lehmeyer (2022) advises against nitrates for lowering blood pressure and recommends urapidil in particular. He also considers adequate analgesia to be necessary to lower blood pressure, as well as normalization of any pathological coagulation values.

This target blood pressure should be achieved within the first 12 - 24 h if possible, whereby the reduction in values should not exceed 5 - 10 mmHg within 4 h using antihypertensives. A more rapid reduction should only be achieved in patients with additional acute myocardial infarction, heart failure, acute renal failure and aortic aneurysm (Schwab 2015).

Stroke as a whole - regardless of the cause - is the third most common cause of death in most industrialized countries. In Germany, the annual incidence is 1.74 / 1,000 inhabitants. Mortality within the first 28 days is 19.4 %, within the first 3 months 28.5 % and after 12 months 37 %. The risk of recurrence after one year is 12 - 13.5 %, after 5 years 30 - 40 % and after 10 years almost 55 % (Linn 2011).

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