Diagnosis and treatment of acute cerebral hemorrhage in patients with hemodialysis

This is a mind map for the diagnosis and treatment of acute cerebral hemorrhage in patients with hemodialysis. The annual incidence of acute cerebral hemorrhage in patients with hemodialysis is (3.0~10.3)/1000, and the main cause is hypertension. Compared with non-dialysis patients, the most common bleeding site is the basal ganglia area, accounting for 50% to 80%; but the bleeding volume is large and the prognosis is poor, and the mortality rate is 27% to 83%. Especially for patients with hematoma >50ml, hematoma enlarged or ventricular hemorrhage on the second day after onset, the prognosis is very poor.

Edited at 2025-02-28 22:38:55

Eeeelizabeth

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Diagnosis and treatment of acute cerebral hemorrhage in patients with hemodialysis

Eeeelizabeth

Recent works View more works>>

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(II) Treatment of acute cerebral hemorrhage in patients with hemodialysis
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Diagnosis and treatment of acute cerebral hemorrhage in patients with hemodialysis

The annual incidence of acute cerebral hemorrhage in patients with hemodialysis is (3.0~10.3)/1000, and the main cause is hypertension. Compared with non-dialysis patients, the most common bleeding site is the basal ganglia area, accounting for 50% to 80%; but the bleeding volume is large and the prognosis is poor, and the mortality rate is 27% to 83%. Especially for patients with hematoma >50ml, hematoma enlargement or ventricular hemorrhage on the second day after onset, the prognosis is very poor.

(I) Diagnosis of acute cerebral hemorrhage in patients with hemodialysis

1. If sudden focal neurological symptoms (facial or limb weakness or numbness on one side, language disorders, etc.), acute cerebrovascular disease should be considered first; patients with vomiting, systolic blood pressure >220mmHg, severe headache, coma or consciousness disorder, and symptoms progress within minutes or hours all indicate acute cerebral hemorrhage.

2. Patients with the above clinical manifestations should undergo rapid neuroimaging [computed tomography (CT) or magnetic resonance imaging (MRI)] after evaluating the patient's vital signs and airway, respiratory and circulatory functions to distinguish between cerebral hemorrhage and ischemic stroke.

(1) The diagnosis of acute cerebral hemorrhage by CT is very sensitive. It is the first choice for imaging examination of acute cerebral hemorrhage and is also the "gold standard" for diagnosis.

(2) Magnetic resonance gradient echo sequence and T2-weighted imaging are comparable to CT sensitivity for the diagnosis of acute bleeding, and are better at identifying old bleeding; susceptibility weighted imaging (SWI) is very sensitive to small or trace cerebral hemorrhage.

(3) CT angiography (CTA) and enhanced CT scans may help identify patients who are prone to early hematoma expansion. The "spot signs" that appear on CTA examination are predictors of early hematoma expansion. Enhanced CT scans found that contrast agent spilling into the hematoma is an important evidence of high risk of hematoma expansion. CT perfusion imaging can reflect the hemodynamic changes in brain tissue after cerebral hemorrhage and understand the blood perfusion around the hematoma.

(4) When clinical manifestations or imaging characteristics suggest vascular lesions, CT angiography, enhanced CT scan, magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) examinations can be performed to detect potential vascular lesions such as intracranial arteriovenous malformations and hemangiomas. However, dialysis patients can induce nephrogenic systemic fibrosis and should be taken seriously.

3. Diagnostic criteria for acute cerebral hemorrhage

(1) Acute cerebral hemorrhage can be diagnosed based on clinical symptoms and signs such as sudden onset, severe headache and vomiting, and neurological dysfunction, combined with imaging results such as CT scans.

(2) The diagnosis of primary cerebral hemorrhage, especially hypertensive cerebral hemorrhage, requires the rule of various secondary cerebral hemorrhage diseases, and the diagnosis must meet all the following conditions:

1) Exact history of hypertension.

2) Typical hemorrhage sites (including basal ganglia, ventricle, thalamus, brainstem, and cerebellar hemisphere).

3) DSA, CTA, and MRA exclude secondary cerebrovascular diseases.

4) Early (within 72h) or late (after 3 weeks of hematoma disappearance) enhancement MRI eliminates brain tumors or cavernous vascular malformations and other diseases.

5) Eliminate various coagulation dysfunction diseases.

(II) Treatment of acute cerebral hemorrhage in patients with hemodialysis

1. If the clinical manifestations of acute cerebral hemorrhage occur during dialysis, the anticoagulant infusion should be stopped immediately and the machine should be removed quickly.

2. For hemodialysis patients who diagnose acute cerebral hemorrhage, it is recommended to transfer to the stroke unit or neurology monitoring room for treatment. The patient's respiratory, oxygen inhalation, temperature control and blood sugar control are the same as those of non-dialysis patients.

3. Patients with large cerebral hemorrhage accompanied by cerebral edema, elevated intracranial pressure (predicted bleeding volume > 30 ml) or ventricular hemorrhage should evaluate the indications for surgical emergency surgery, and the surgical indications are those of non-dialysis patients.

4. Intracranial hypertension treatment for patients with acute cerebral hemorrhage caused by hemodialysis is recommended for intravenous injection of glycerol fructose. However, after injecting glycerol fructose intravenously, water cannot be eliminated from the urine, which can increase circulating blood volume; therefore, it is recommended to use glycerol fructose during dialysis.

5. It is recommended to actively control blood pressure from the acute phase

(1) Patients with systolic blood pressure >180mmHg or average arterial pressure >130mmHg, it is recommended that the previous value of blood pressure 80% is used as the target of lowering blood pressure, and slowly lowering blood pressure; systolic blood pressure <140mmHg helps prevent the hematoma from expanding. Antihypertensive drugs are selected for nicardipine, diltiazepine hydrochloride, nitroglycerin and sodium nitroprusside intravenous infusion.

(2) To prevent recurrence of cerebral hemorrhage, it is recommended to control diastolic pressure <90mmHg.

(3) Prevent the occurrence of cerebral hemorrhage and control blood pressure <140/90mmHg is beneficial.

6. The incidence of microcerebellar hemorrhage in patients with long-term hypertension or previous cerebrovascular diseases is 19% to 35%. SWI examination is recommended for this type of patients, and CT angiography, MRI contrast-free angiography, and digital subtraction angiography are performed when necessary to detect potential vascular lesions such as intracranial arteriovenous malformations and hemangiomas.

7. Hemodialysis treatment for acute cerebral hemorrhage in patients with hemodialysis

(1) Avoid hemodialysis within 24 hours of acute cerebral hemorrhage.

(2) Select dialysis methods that affect less intracranial pressure in the early stage of onset: ① Continuous hemodialysis filtration; ② Peritoneal dialysis; ③ Daily inefficient and slow hemodialysis.

(3) Glycerol fructose is given intravenous injection during dialysis, combined with ultrafiltration treatment to reduce intracranial pressure.

(4) Citrate can be used for local anticoagulant. Warfarin is discontinued and vitamin K is given; protamine antagonism is given in patients who use warfarin or low molecular weight heparin.