Primary intracerebral and subarachnoid hemorrhage an approach to diagnosis and therapy

Fisher, Marc

doi:10.1590/S0004-282X1991000300001

Abstracts

The diagnosis of primary intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) has become easier with the advent of modern imaging techniques. The incidence of ICH has declined, while SAH has remained relatively constant. The prognosis for both disorders remains dismal and the mortality rate is substantially higher than that observed with ischemic stroke. Early imaging with CT or MRI is important for rapid and accurate diagnosis. General medical management in a skilled nursing facility should be available for patients who are not moribund. Therapy for ICH is predominantly supportive and effective medical and surgical intervention remains elusive. For SAH, calcium channel blockers may reduce cerebral ischemic complications related to vasospasm, but effective medical therapy to prevent rebleeding has not been established. Early surgery after SAH should be considered in clinically stable patients. Many challenges remain regarding the prevention and treatment of both these cerebral hemorrhage subtypes.

O diagnóstico da hemorragia intracerebral primária (HIP), bem como o da hemorragia subaracnóidea (HSA), ficou mais fácil com o advento das modernas técnicas de imagem. A incidência da HIC tem declinado, ao passo que a da HSA tem permanecido relativamente constante. O prognóstico de ambas ainda é desanimador e a taxa de mortalidade substancialmente maior que a observada nas afecções isquêmicas. A indicação precoce da TC ou da RNM do crânio é importante para um diagnóstico rápido e preciso. Pacientes que não estejam moribundos devem receber cuidados médicos gerais em instalações com equipes de enfermagem especializada. O tratamento da HIC é predominantemente de apoio e intervenções médicas e cirúrgicas continuam indefinidas. Quanto a HSA, bloqueadores dos canais de cálcio podem reduzir as complicações cerebrais isquêmicas relacionadas ao vasoespasmo, mas não se estabeleceram tratamentos médicos eficazes para prevenir novos sangramentos. Naqueles pacientes clinicamente estáveis, deve-se considerar a antecipação da cirurgia. Muitos desafios permanecem no tocante à prevenção e ao tratamento desses dois subtipos de hemorragia cerebral.

CONTENTS CONTEÚDO

Marc Fisher

MD, Department of Neurology, The Medical Center of Central Massachusetts and The University of Massachusetts Medical School

SUMMARY

The diagnosis of primary intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) has become easier with the advent of modern imaging techniques. The incidence of ICH has declined, while SAH has remained relatively constant. The prognosis for both disorders remains dismal and the mortality rate is substantially higher than that observed with ischemic stroke. Early imaging with CT or MRI is important for rapid and accurate diagnosis. General medical management in a skilled nursing facility should be available for patients who are not moribund. Therapy for ICH is predominantly supportive and effective medical and surgical intervention remains elusive. For SAH, calcium channel blockers may reduce cerebral ischemic complications related to vasospasm, but effective medical therapy to prevent rebleeding has not been established. Early surgery after SAH should be considered in clinically stable patients. Many challenges remain regarding the prevention and treatment of both these cerebral hemorrhage subtypes.

RESUMO

O diagnóstico da hemorragia intracerebral primária (HIP), bem como o da hemorragia subaracnóidea (HSA), ficou mais fácil com o advento das modernas técnicas de imagem. A incidência da HIC tem declinado, ao passo que a da HSA tem permanecido relativamente constante. O prognóstico de ambas ainda é desanimador e a taxa de mortalidade substancialmente maior que a observada nas afecções isquêmicas. A indicação precoce da TC ou da RNM do crânio é importante para um diagnóstico rápido e preciso. Pacientes que não estejam moribundos devem receber cuidados médicos gerais em instalações com equipes de enfermagem especializada. O tratamento da HIC é predominantemente de apoio e intervenções médicas e cirúrgicas continuam indefinidas. Quanto a HSA, bloqueadores dos canais de cálcio podem reduzir as complicações cerebrais isquêmicas relacionadas ao vasoespasmo, mas não se estabeleceram tratamentos médicos eficazes para prevenir novos sangramentos. Naqueles pacientes clinicamente estáveis, deve-se considerar a antecipação da cirurgia. Muitos desafios permanecem no tocante à prevenção e ao tratamento desses dois subtipos de hemorragia cerebral.

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Marc Fisher, MD - The Medical Center of Central Massachusetts - 119 Belmont Street - Worcester, MA, 01605 - USA.

1. Adams HP. Antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage: Do they have a role? Maybe. J Neurosurg 1987, 44:114-115.
2. Adams HP, Kassell NF, Torner JC. Usefulness of computed tomography in predicting outcome after aneurysmal subarachnoid hemorrhage. Neurology 1985, 35:1263-1267.
3. Adams HP, Kassell NF, Torner JC, Sahs AL. CT and clinical correlation in recent aneurysmal subarachnoid hemorrhage. Neurology 1983, 33:981-988.
4. Bartleson JD, Trautmann JC, Sundt TM. Minimal oculomotor nerve paresis secondary to unruptured intracranial aneurysm. Arch Neurol 1986, 43:1015-1020.
5. Batjer HH, Reisch JS, Allen BC, Plazier LC, Su CJ. Failure of surgery to improve outcome in hypertensive intracranial hemorrhage. Arch Neurol 1990, 47:1103-1106.
6. Becker DH, Townsend JJ, Kramer RA, Newton T. Occult cerebrovascular malformations: a series of 18 histological verified cases with negative angiography. Brain 1979, 102:249-287.
7. Berger AR, Lipton RB, Lesser ML (et al). Early seizures following intracerebral hemorrhage. Neurology 1988, 38:1363-1365.
8. Biller J, Bodersky JC, Adams HP. Management of aneurysmal subarachnoid hemorrhage. Stroke 1988, 19:1300-1305.
S. Bitoh S, Hassegawa H, Ohtsuki H (et al). Cerebral neoplasms initially presenting with massive intracerebral hemorrhage. Surg Neurol 1989, 22:57-62.
10. Brott T, Thalinger K, Herteberg . Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke 1986, 17:1978-1983.
11. Caplan L. Intracerebral hemorrhage revisited. Neurology 1988, 38:624-627.
12 Cerebral Embolism Study Group. Cardioembolie stroke, early anticoagulation and brain hemorrhage. Arch Intern Med 1987, 147:636-640.
13 Charcot J-M, Bouchard C. Nouvelles recherches sur la pathogénie de l'hémorrhagie cerebrate (three parts). Arch Physiol Norm Pathol 1868, 1:110-127 ; 643-665; 725-734.
14. Chen ST, Chen SD, Hsu C, Hogan EL. Progression of intracerebral hemorrhage. Neurology 1989, 39:1509-1514.
15. Cosgrove CR, Leblanc R, Meagher-Villemure K, Ethier R. Cerebral amyloid angiopathy. Neurology 1985, 35:625-631.
16. Dooms GC, Vske A, Brant-Zawadzki M (et al). Spin-echo MR imaging of intracerebral hemorrhage. Neuroradiology 1986, 28:132-138.
17. Fennerty AB, Levine MN, Hirsch J. Hemorrhagic complications of thrombolytic therapy in the treatment of myocardial infarction and venous thromboembolism. Chest 1989,95:88S-97S.
18. Fisher CM. Pathological observations in hypertensive cerebral hemorrhage. J Neuropathol Exp Neurol 1971, 30:536-550.
19. Goto N, Kaneko M, Hosaka Y, Koga H. Primary pontine hemorrhage: clinicopathological correlations. Stroke 1980, 11:84-90.
20. Heros RC. Cerebellar hemorrhage and infarction. Stroke 1982, 13:106-109.
21. Kase CS, Fisher M, Babikian VL, Mohr JP. Cerebrovascular Disease. In Rosenburg RN (ed): Neurology. New York; Raven Press, 1991.
22. Kase CS, O'Neal AM, Fisher M (et al). Intracerebral hemorrhage after use of tissue plasminogen activator for coronary thrombolysis. Ann Intern Med 1990, 112:17-21.
23. Kase CS, Robinson RK, Stein RW (et al). Anticoagulant related intracerebral hemorrhage. Neurology 1985, 35:943-998.
24. Kase CS, Williams JP, Wyatt DA, Mohr JP. Lobar intracerebral hemorrhage: clinical and CT analysis of 22 cases. Neurology 1982, 32:1146-1150.
25. Kassel NF, Torner JC, Adams HP. Antifibrinolythic therapy in the acute period following aneurysmal subarachnoid hemorrhage. J Neurosurg 1989, 61:225-230.
26. Kassel NF, Torner JC, Jane JA (et al). The international cooperative study on the timing of aneurysm surgery: surgical results. J Neurosurg 1990. 73:37-47.
27. Kaufman HH, Boake JL, Olson JD (et al). Delayed and recurrent intracranial hematomas related to disseminated intravascular clotting and fibrinolysis in head injury. Neurosurgery 1980, 7:445-449.
28. Levine S. Cocaine and stroke. Stroke 1987, 22:25-29.
29. Longstreth WT, Koepsell TD, Yerby MS, van Belle G. Risk factors for subarachnoid hemorrhage. Stroke 1985, 16:377-385.
30. Mohr JP, Caplan LR, Belski JW (et al). The Harvard Cooperative Stroke Registry. Neurology 1978, 28:754-762.
31. Omae T, Veda K, Ogata J, Yamaguchi T. Parenchymatous hemorrhage : etiology, pathology and clinical aspects. In Vinken PJ, Bruyn GW, Klawans HL (eds) : Handbook of Clinical Neurology. Ed 2. Amsterdam: Elsevier, 1989, p 287-231.
32. Pickard JD, Murray GO, Illingworth R (et al). Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid hemorrhage. Br Med J 1989, 289:636-642.
33. Poungvarin N, Bhoopat N, Viniyarejakul A (et al). Effects of dexamethasone in primary supratentorial hemorrhage. N Engl J Med 1987, 316:1229-1233.
34. Przelomski MM, Fisher M, Davidson RI (et al). Unruptured intracranial aneurysm and transient focal cerebral ischemia. Neurology 1986, 36:584-587.
35. Sacco RL, Wolf PA, Bharucha NE. Subarachnoid hemorrhage and intracranial aneurysms: natural history, prognosis and precursive factors in the Framingham Study. Neurology 1989, 34:847-854.
36. Sekher LN, Heros RC. Origin, growth and rupture of saccular aneurysms. Neurosurgery 1981, 8:248-259.
37. Stebbens WE. Pathology of the Cerebral Blood Vessels. St Louis : Mosby, 1971.
38. Tuhrim S, Dambrosia JM, Price TR (et al). Prediction of intracerebral hemorrhage survival. Ann Neurol 1988, 24:258.
39. Vassilouthis J, Richardsen AE. Ventricular dilation and communicating hydrocephalus following spontaneous subarachnoid hemorrhage. J Neurosurg 1979, 51:341-351.
40. Vwerweig RD, Wijdiek EM, van Gign J. Warning headache in aneurysmal subarachnoid hemorrhage. Arch Neurol 1988, 45:1019-1020.
41. Walshe TM, Davis KR, Fisher CM. Thalamic hemorrhage: a computed tomographic--clinical correlation. Neurology 1977, 27:217-222.
42. West HH, Mani RL, Eisenberg RL, Turek K, Stucker TB. Normal cerebral angiography in patients with spontaneous subarachnoid hemorrhage. Neurology 1977, 27 : 592-594.
43. Wiebers DO, Whisnant JP, O'Fallon WM. The natural history of unruptured intracranial aneurysms. N Engl J Med 1981, 304:696-698.
44. Yatsu FM, Decker C, McElroy KR (et al). Community hospital-based stroke programs. Stroke 1986, 17:276.
45. Young S, Fisher M, Davidson R. Cerebrovascular disease. In Rippe JM (ed) : Intensive Care Medicine. Boston : Little Brown. 1991.