Intra Cerebral Hemorrhage :
Rupture of blood vessels deep inside the brain due to high blood pressure is called intracerebral hemorrhage. This hemorrhage occurs at some particular locations in the brain (like Putamen, Thalamus, Cerebellum) and usually while examining the patient; the physician can easily identify the location, by its specific signs and symptoms.
Amyloid Angiopathy is s a kind of cerebral hemorrhage occurring mostly in elderly people and it can recur frequently.
If all these hemorrhages are diagnosed quickly and immediate treatment is initiated to reduce the edema of the brain and control of blood pressure, the death rate in the cases of cerebral hemorrhage can be brought down considerably. At present the death rate is as high as 50% to 60%. In some cases of cerebellarhemorrhage, e.g. temporal lobe hemorrhage or putaminal hemorrhage, lives can be saved by surgery done by a neurosurgeon. The goal of reducing death rate due to cerebral hemorrhage can be achieved by factors like awareness about the disease, quick diagnosis, treatment at a war footing, expert and quick decision making physicians and neurosurgeons and hospitals with all amenities like ventilator machine, operation theatre etc.
Sudden headache, vomiting, vertigo, blackouts (these can be due to high blood pressure also), seizures, stumbling, paralysis, and loss of consciousness within a few minutes with rapid breathing; are the usual symptoms of brain hemorrhage.
It is essential to get an immediate diagnosis with a CT scan or MRI scan. These tests can also identify the location of the hemorrhage, the size of the clot, edema of the brain and the cause of the same. It is better to get a CT scan done even before admission, if the facility is available in the city or town, provided the patient is stable with normal respiration and B.P.. This is for confirmation of the hemorrhage. Even if clinically, a hemorrhage is suspected, the scan some times may reveal a thrombosis, tumor, subdural or cerebral infection’ and that would make a major difference in the line of treatment. However, emergency treatment in a hospital should be given immediately and the scan may be done later if the condition of the patient is serious.
It is essential to create awareness in the public that in any serious neurological condition, instead of wasting time by insisting on a home visit by the specialist, it is advisable to immediately call the family doctor and rush the patient to the hospital with an ambulance and if required get a scan done before admission. If the specialist doctor can visit immediately, it would be excellent. But usually it may take 2 to 4 hours for him to be available, during which precious time is lost and the delay in treatment may cause irreparable damage to the brain. If the family doctor also is unable to make it on time,then the best option would be to take the patient immediately to the emergency ward of a good hospital and arrange for the specialist to reach there. Such a detailed explanation has basically been given on this subject because in majority of the cases exactly the opposite is seen to be happening and it leads to immense regret. Emergency medicine and, critical care is a separate and extremely important aspect of the medical fraternity. Here every second counts and critical decisions taken by the specialized doctors, who are well trained to save lives, play a very important role. Therefore, in this matter no social arguments or interference should be entertained.
In a case of hemorrhage, if blood pressure is found high by the family physician, immediate treatment for controlling the blood pressure is given. If there is an indication of thrombosis, then the blood pressure should not be abruptly brought down as it can cause a lot of damage. But if the blood pressure is very high or the patient is suffering from heart disease, or the patient is on anticoagulant therapy, it becomes very essential to lower the blood pressure to normal level even in case of thrombosis.
If the edema of the brain seems substantial, then emergency injections (mannitol, lasix) can be given by the family physician at home, before transferring the patient to the hospital. If the patient is getting seizures, then one should not wait, but start urgent treatment at home.
Sometimes lumbar puncture could be useful apart from CT scan, in the diagnostic process, but as mentioned later in the chapter on brain tumors, lumbar puncture is to be avoided if there is edema in the brain. Here it may prove dangerous.Naturally, these patients are kept in ICU They are monitored very intensively along with emergency treatment: If required angiography is performed and in selected cases surgery is done to aspirate blood.
If the cause of the hemorrhage is a deficiency of any of the blood clotting factors, the deficiency is corrected by transfusion of those factors. If the hemorrhage has occurred due to the side effects of any drug (like Warf, Acetrom which are given in cases of valvular defects) then plasma and other appropriate blood components are transfused to stop hemorrhage. In the medical profession hemorrhage is one of the most serious side effects of these drugs. The drugs, which prevent the clotting of the blood, can -cause hemorrhage due to overdose in some cases. Therefore, it is very important to inform the patient in detail about the side effects of the medicine. Every 7 to 15 days Prothrombin time APTT/INR blood test has to be carried out regularly to monitor the thinning of the blood. If proper precautions are taken, no side effects occur and the patients lead a complication free life for years at a stretch. Just as insulin is extremely beneficial for a diabetic patient to lead a normal life, but an unrequired higher dose may cause hypoglycemia and even death. Same holds true for anticoagulant drugs.
Thus regulation of blood pressure, medicines for the edema of the brain, proper nursing, treatment of complications, and if required surgery can save the patients of intra cerebral hemorrhage to a large extent. If the patient is saved but paralysis persists as a consequence of the hemorrhage, physiotherapy along with drugs should be used for a longperiod of time to activate the paralyzed limbs once again. It is a fact that the initial chances of death are much higher in hemorrhage than in thrombosis, but so is also a fact that recovery from paralysis due to hemorrhage is much better than in thrombosis. For care of sick patients, certain guidelines are given in chapter 24, which may be followed strictly by the care taker.
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