How can a cerebral hemorrhage be treated?
It is important to react early to the symptoms of a cerebral hemorrhage and, following imaging of a cerebral hemorrhage, to initiate therapy quickly in order to prevent secondary bleeding in the first 24 hours, which occurs untreated in more than a third of patients, and to minimize consequential damage, for example by reducing the increased intracranial pressure. A fundamental distinction is made between conservative and surgical measures and rehabilitative follow-up treatment. Within the framework of conservative therapy, the first step is to try to prevent the expansion of bleeding and an increase in intracranial pressure, which correlates with brain perfusion.
Many of the patients require intensive medical treatment. In addition to monitoring vital body functions (vital parameters), e.g. pulse, blood pressure and temperature, this includes artificial respiration with the aid of a ventilator introduced into the airways (intubation) in order to maintain the oxygen supply in severely mentally impaired patients. Patients whose condition is critical must be monitored in an intensive care unit, while awake patients can be cared for in a stroke unit.
In the first few hours to days after ICB, blood pressure should be adjusted with medication if it is too high in the patient, but it should be noted that if it is lowered too quickly and too much, the nerve tissue around the site of bleeding may be less well supplied and additional brain damage may result. Urapidil and clonidine (Catapressan) are most frequently used to lower blood pressure. Urapidil is mainly used for acute blood pressure increases.
It blocks alpha 1 vascular receptors in the periphery, which leads to a decrease in vascular resistance and thus lowers blood pressure. In addition, it acts via central serotonin receptors and thus suppresses a counterregulation that is normally triggered by the sympathetic nervous system. This normally causes a counter-reaction at the heart in the sense of an increased heart rate (tachycardia) and an increase in the heart’s beating power (contractility).
Urapidil is used in the treatment of high blood pressure (arterial hypertension). Side effects may 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 neurotransmitter that is part of the sympathetic nervous system. This in turn reduces the heart rate (bradycardia) and lowers blood pressure (hypotension). When ingested initially, an increase in blood pressure (hypertension) may occur, since clonidine also acts non-specifically on other receptors.
Side effects include the typical symptoms that occur when the sympathetic nervous system is slowed down, including dry mouth, sluggish stomach and intestines, constipation, fatigue and dizziness. Clonidine is enhanced in its effectiveness by various substances. These include alcohol and antidepressants.
The treatment of coagulation disorders, which have already been mentioned as a risk factor, is also important. One option is substitution therapy, i.e. the replacement of missing clotting factors. In the case of a cerebral hemorrhage under heparin treatment, protamine sulfate can be administered as an antidote.
The therapeutic dilemma often exists that patients who have been on anticoagulant therapy for many years cannot suddenly stop it, but remain dependent on the therapy, for example because of artificial heart valves and a resulting increased risk of blood clots being deposited. Vascular malformations in the brain, e.g. cavernomas, which are responsible for ICB, must be repaired early on in order to rule out repeated bleeding. Since epileptic seizures can also occur in about 10% of patients with large intracerebral bleedings, anti-epileptic drugs are administered prophylactically or when a seizure occurs.
Blood sugar should be kept within the normal range and an increase (hyperglycaemia) should be avoided. If the spaces of the brain (ventricles) filled with cerebrospinal fluid (cerebrospinal fluid) become increasingly dilated, an artificial drain can be surgically created to reduce the pressure and thus prevent mass shifts of the brain and constrictions. There are studies investigating a yet unapproved drug, recombinant factor 7a, which in initial studies was able to reduce the rate of post-bleeding when administered within the first hours after bleeding.Depending on the location and size of the bleeding, as well as the patient’s age and state of consciousness, bleeding can also be removed surgically.
Surgery is particularly suitable for hemorrhages in the brainstem region, 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 the conservative treatment of intracerebral hemorrhage. The benefit-risk ratio of a surgical intervention must therefore be decided for the individual. Subsequent to early therapy measures are: important depending on the pattern of failure, as well as the treatment of risk factors and causes of bleeding.
- Physiotherapy,
- Speech therapy and
- Ergotherapy
