Hemorrhagic stroke

“ There are few symptoms which are more likely to excite alarm and apprehension of a stroke of paralysis than vertigo or attacks of dizziness, but it is too common under a great variety of circumstances to have much value, and is, as a matter of fact, rarely a distant precursor of intracranial hemorrhage, although it frequently appears among the almost initiatory symptoms, especially when the lesion is in the cerebellum, so that, if continuous, it is not likely to mean that anything worse is coming. ”

“ In cerebral meningeal hemorrhage and in effusion into the substance of the brain the blood sometimes escapes into the spinal canal. An aneurism of the aorta has been known to communicate with the canal; such a case was reported by Laennec.12 In certain diseases with hemorrhagic tendency, as purpura and scurvy, spinal extravasation is occasionally observed.13 ”

“ Another special danger is rupture of the blood-vessels, particularly of the brain. In the condition of general arterial degeneration associated with contracted kidneys and hypertrophied left heart apoplexy is common; indeed, we may say that in the majority of cases of cerebral hemorrhage there is sclerosis of the cerebral vessels, often with the development of miliary aneurisms, and the rupture is directly induced by the forcible action of the heart. ”

“ When, however, blood is found effused on the surface of the brain, especially between the dura mater and the skull, either beneath or opposite to an external wound, we may reasonably infer that the hæmorrhage is due to a direct blow. Hæmorrhage so severe as to produce dangerous pressure on the brain, as a rule, comes from a rupture of the middle meningeal artery. ”

“ The absolute and relative size of cortex and medulla, and the distinctness of the boundary between them, should be noted.
Hemorrhages may occur in any part of the brain, and may be large or small. Rupture into a ventricle is always fatal. The large hemorrhages are due to rupture of a diseased artery; small punctate hemorrhages throughout cortex are usually embolic (fatty embolism) . Old hemorrhages are brownish in color (pigment) . Areas of softening are usually the result of embolism, thrombosis or sclerosis. ”

“ I remember seeing in Mendel's clinic, in Berlin, a man who was suffering from his seventh stroke and promised to recover to have another. Each successive stroke is much more dangerous to life than the preceding one, however. In general, the prognosis of an apoplexy, that is to say what the ultimate result will be, is impossible. The patient may come to in an hour or two, and may not come out of the coma at all. There is no way of deciding how large the artery is that is ruptured, nor how much blood has been effused into the brain, nor how much damage has been done to important nerve centres. ”

“ The blood poured out upon the brain from an apoplectic stroke, must, and does, prove fatal, save when the vis medicatrix is able to interpose in time, by encircling the fluid, enclosing it with a sac, and subsequently by absorption removing the extraneous pressure. All these are vital processes, over which the sufferer has no control—of which he is not even conscious. ”

“ Where the motor fibers from the whole cortex are gathered together in one compact bundle, a very small hemorrhage may and does cause very serious effects. A comparatively large hemorrhage in the silent area of the brain may cause few or no symptoms. ”

“ A subdural hemorrhage may cause almost the same symptoms, though the injury is usually such as has produced a depressed fracture. This hemorrhage is most often due to the rupture of a number of small vessels under the fracture, though if one larger vessel is ruptured it is most often the middle cerebral. A thin layer of hemorrhage in connection with a superficial laceration of the brain is of frequent occurrence with or without the other two forms of intracranial hemorrhage. If the brain is lacerated we may have convulsions in addition to other symptoms. ”

“ There are only four ways of arresting arterial [Pg 126] hemorrhage. First, by cautery; second, by division of the artery, when that is not complete—for then the extremities contract and the blood clots—or by a ligature, or by the application of substances which arrest blood flow, aided by a compressive bandage. Other means are inefficient, and seldom and, at most, accidentally successful. His instruction for first aid to the injured in case of hemorrhage in the absence of the physician, is to apply pressure directly upon the wound itself. ”

“ Quite different would it be should one of the small arteries of the brain, the lenticulo-striate, for example, which supplies the corpus striatum, become the seat of a thrombosis or embolism caused by arteriosclerosis. The arteries of the brain are terminal [195] arteries and the blood supply would be cut off entirely with a resulting anemic necrosis of the part supplied by the artery and a loss of function of the part. What would be of no moment in the leg or arm might prove even fatal in the brain. ”

“ Extra-dural hæmorrhage may be arterial or venous in origin. In the former case the blood is derived almost exclusively from the middle meningeal artery. When of venous origin the source is usually to be found in a laceration of one of the sinuses of the brain. When blood is poured out from a torn sinus it tends to occupy, and be widely diffused in, the subdural space. A venous extra-dural extravasation is relatively of infrequent occurrence, and the pressure exercised on the brain seldom suffices to permit of the development of local or general symptoms of cerebral compression. ”

“ From the above considerations we see that spontaneous cerebral hemorrhage and that due to disease are not always easily distinguished from that due to violence. In severe injuries the structure of the brain is plainly bruised, etc., but the greatest difficulty exists in cases of slight violence where arteritis of the cerebral blood-vessels coexists. ”

“ In children meningeal hemorrhage is, with only a few exceptions, the usual lesion of apoplexy. The blood is usually dark and coagulated in recent cases. Blood found under the membranes where no fracture has taken place is, however, more likely to have been derived from the brain-substance and to form part of a cerebral hemorrhage. ”

“ Rowan finds, as has long been recognized, that a conclusion as to whether or not cerebral hemorrhage will occur cannot be made from the condition of the radial arteries, as patients with soft radials may suffer from cerebral hemorrhage, while those "with hard, sclerosed, pipestem-like arteries may live to a great age and die of anything rather than apoplexy." ”

“ If the loss of consciousness be not complete, so that the presence or absence of paralysis can be ascertained, we can sometimes distinguish the situation of the hemorrhage. Right-sided hemiplegia, with paralysis of the face or tongue, or with aphasia, is most probably owing to hemorrhage or [p. 715] embolism somewhere in the left motor tract, and hence within the brain. If the absence of paralysis can be certainly ascertained, the probabilities are in favor of meningeal apoplexy. ”

“ In the meantime, with the advancing degeneration of the cerebral arteries, some sudden cerebral congestion, caused by leaning over, lifting, vomiting or hard coughing, may rupture a cerebral vessel, and all the symptoms of apoplexy are present. If small hemorrhages occur in the arterioles of the extremities, of course the prognosis is not serious. Sometimes some of the smaller vessels of the brain may become obstructed and cerebral degeneration occur. ”

“ When serum is effused, a pituitous or purulent expectoration alone takes place; when blood is discharged, a disease is produced which has been called hæmoptysis. An effusion of blood in the brain, brought on by the operation of general debility, has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of the brain. The effusion of blood in the lungs, in consequence of the rupture of a blood-vessel, is less fatal than the same accident when it occurs in the brain, only because the blood in the former case is more easily discharged from the system. ”

“ Then, too, in the act of falling from the occurrence of a cerebral hemorrhage due to disease the head may be injured and show marks of violence. It should be borne in mind that an injury to the head may be inflicted when disease of the brain, vessels, or membranes already exists. In such a case a slight blow might cause extensive hemorrhage, but as that which accelerates causes, death, even though it might sooner or later have occurred in the same manner without injury, is due to the injury inflicted. ”

“ In a case of cerebral hemorrhage of considerable size the pressure is distributed over a space much exceeding the area of the clot itself, and renders a large part of at least one hemisphere anæmic. If the blood finds its way into the ventricles, the conditions are most favorable for compressing nearly the whole brain. ”

“ Complete muscular resolution is most common when the effusion is bilateral, but when the hemorrhage is limited to one side more or less paralysis of the opposite limbs may exist. Should the blood make its way into the spinal canal, it might give rise to special symptoms, but this is not probable in view of the large amount of the cerebral effusion under the circumstances, which would produce complete insensibility or speedily cause death by pressure on the medulla. ”

“ Middle meningeal hæmorrhage, uncomplicated by brain injury, is of infrequent occurrence, the associated injuries to bone and brain confusing the diagnosis. Moreover, the special pressure effects are dependent not only on the absence of serious brain lesion, but also on the non-existence of a safety-valve, such, for instance, as is afforded by a comminuted fracture of the bones entering into the formation of the temporal fossa, or of the roof of the middle and external ears. ”

“ If an artery is only _partly cut across_, the divided fibres of the tunica muscularis contract and those of the tunica externa retract, with the result that a more or less circular hole is formed in the wall of the vessel, from which free bleeding takes place, as the conditions are unfavourable for the formation of an occluding clot. Even if a clot does form, when the blood-pressure rises it is readily displaced, leading to reactionary haemorrhage. Should the wound become infected, secondary haemorrhage is specially liable to occur. ”

“ So far as we can tell, the causes leading to endarteritis or atheroma are essentially the same as those which produce the periarteritis described in connection with cerebral hemorrhage, and we may therefore put down old age, alcohol, and strain as among the causes of cerebral embolism. Injuries of the lungs leading to thrombosis of the veins may be considered as possible sources for the formation of an embolus, and we might suppose that phthisis and pneumonia would furnish plugs which would lodge in the brain, though as a matter of fact they seldom do so. ”

“ The danger of an embolus plugging one of the smaller arteries is great and probably happens more often than we think. The collateral circulation is able to supply the thrombosed area. Should the thrombus be on the carotid arteries, hemiplegia may result from cerebral embolism. On microscopic examination of the arteries there is seen extreme degeneration of all the coats, the degeneration of the media leading almost to an obliteration of that coat. On seeing such arteries as these one wonders how the circulation could have been maintained and the organs nourished. ”

“ The hemorrhage increased, and the force of the pulsation became much greater. At these times so great was the alternate heaving and bulging of the brain, that we were compelled to suspend operations until they were quieted by a repetition of the remedy. Then the pulsations would diminish, the cerebral surface recede within the opening of the skull, as if by collapse; the appearance of the organ becoming pale and shrunken with a cessation of the bleeding. In fact, we were convinced that diminished vascularity of the brain was an invariable result of the impression of chloroform or ether. ”

“ It may be associated with concussion or laceration of the cord. It may destroy life directly by extension or indirectly by leading to a spreading inflammation. Hemorrhage in or about the cord causes a gradual compression of the cord, and in cases of fracture of the spine often adds to the compression due to the displacement of the bones. In hemorrhage into the substance of the cord paralysis comes on early or immediately and may be complete while symptoms of irritation fail. ”

“ Larger aneurisms, often multiple, are not very infrequent upon the arteries at the base of the brain. They may before their rupture give rise to symptoms of pressure like any other tumor, and may also be the source of hemorrhage, which is usually meningeal. They are not infrequently symmetrical, and a place of election is one of the early bifurcations of the middle cerebral. ”

“ The first haemorrhage is often slight and stops naturally, but it soon recurs, and is so profuse, especially when the blood escapes externally, that it rapidly proves fatal. When the bleeding takes place into the cellular tissue, the aneurysm is said to become _diffused_, and the extravasated blood spreads widely through the tissues, exerting great pressure on the surrounding structures. ”

“ Generally, however, untoward symptoms result sooner or later in such cases. Hemorrhage occurs from the injured part, and a clot protrudes from the external wound. Or the cerebral substance in the neighbourhood of the wound softens, and becomes converted into a semifluid mass, often mixed with pus; and a fungous growth,233 connected with the disorganised matter, gradually protrudes through the aperture in the cranium, and is repressed with difficulty. If removed by knife or ligature, it is rapidly reproduced. Pressure is the only means left by which to attempt its retardation ”