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*It is the responsibility and obligation of physicians to ensure a good prognosis for patients only for reference by medical professionals.
Brainstem hemorrhage (brainstem hemorrhage) accounts for about 10% of clinical cerebral hemorrhage cases.
Although the incidence is not high, it has a rapid onset, a dangerous condition, and a poor prognosis.
It has the highest mortality and disability rate among all cerebrovascular diseases, and its prognosis The worst type of cerebrovascular disease.
The overwhelming majority are pons hemorrhage, caused by the rupture of the pontine branch of the basilar artery, occasionally hemorrhage in the midbrain and bulbar hemorrhage are extremely rare.
The clinical manifestations of brainstem hemorrhage are mostly sudden headache, dizziness, vomiting, diplopia, different ocular axes, lateral vision paralysis, cross paralysis or hemiplegia, quadriplegia, etc.
When massive hemorrhage (>5ml) occurs, the hematoma spreads to the base and tegmental part of the pons, and the patient quickly enters into disturbance of consciousness and even death [1].
The main complications include pulmonary infection, upper gastrointestinal bleeding, dysphagia, water and electrolyte imbalances, central high fever, deep vein thrombosis, and seizures, which should be identified and dealt with as soon as possible.
However, patients with brainstem hemorrhage can also be complicated by exposure keratitis.
If it cannot be detected in time and treated actively and effectively, the severe cases may face the risk of removal of the affected side of the eyeball.
This article conducts a systematic analysis of this complication, so that everyone has a better understanding and scientific treatment.
Case sharing patient, male, Fang Mohua, 38 years old.
On January 10, 2021, he was rushed to our hospital for "sudden loss of consciousness for half an hour".
He has a history of hypertension for several years without formal diagnosis and treatment.
Emergency physical examination: appearance of acute critical illness, moderate coma, snoring breathing, bilateral pupils with equal circles, diameter of about 2.
5 mm, slow reflection of light, inability to close left eye cleft, right angle of mouth, bilateral limb paralysis (left The muscle strength of the lateral limbs is level II to III, and the muscle strength of the right limb is level 0), and the heart, lungs, and abdomen are normal. A plain CT scan of the skull revealed a patchy high-density shadow in the brainstem, with a larger section of about 24mm×10mm, with a clear boundary.
In view of the serious condition, it is recommended to transfer to a higher-level hospital for further diagnosis and treatment, and perform "stereotactic brainstem hematoma removal + cerebrospinal fluid drainage and replacement surgery" on January 13.
After being transferred back to our hospital on March 24, it was found that the patient's left eyeball conjunctiva was hyperemia and edema, and the cornea was foggy and turbid.
Please consider exposure keratitis of the left eye and oculomotor palsy of the left eye after the ophthalmology consultation.
In addition, two other patients with brainstem hemorrhage admitted recently also had similar manifestations.
Figure 1: The patient’s imaging findings and signs.
Brain stem anatomy.
The brain stem is a small part of the central nervous system located between the diencephalon and the spinal cord.
From top to bottom, it consists of the midbrain, pons, and medulla oblongata.
In addition to the olfactory nerve and optic nerve of the cranial nerves, the cranial nerves from Ⅲ to Ⅻ all enter and exit the brainstem.
Among them, the trigeminal nerve is located on the ventral lateral surface of the middle part of the pons, and the branch of the ophthalmic nerve splits from the supraorbit into the orbit, innervating the eyelid, cornea, lacrimal gland and forehead skin.
The main nucleus of the lateral oculomotor nerve is the largest, containing clusters of large neurons, innervating the levator eyelid muscle, medial rectus muscle, superior rectus muscle, inferior rectus muscle and inferior oblique muscle.
Figure 2: Brainstem anatomy, derived from network pathogenesis-related mechanisms.
The cornea is located at the forefront of the eyeball, occupying 1/6 of the surface of the eyeball.
The surface is extremely smooth, transparent and shiny.
There are no blood vessels.
Its nutrition depends on the vascular network and front of the peripheral corneal limbus.
Diffusion and penetration of glucose, oxygen and other substances contained in the tear film and subsequent aqueous humor.
Therefore, the cornea has a slow metabolism and poor resistance.
Once it is damaged, the inflammatory response is obvious, and its self-repair ability is low.
Patients with brainstem hemorrhage often lead to incomplete closure of the upper eyelid due to coma and facial paralysis, and the eye branch of the trigeminal nerve is dull, leading to corneal dryness, inflammatory infiltration, and even corneal ulcers and corneal perforation.
It has been found in clinical practice that exposure keratitis complicated by this disease is generally severely damaged.
Clinical manifestations and treatment mainly include eye pain, redness, irritation, foreign body sensation and sticky secretions, multiple punctate exfoliation of the corneal epithelium, and some patients have severe clinical symptoms, recurrent episodes and a long course of disease [2].
Treatment: (1) First, clean the eye secretions, then massage the eyelid margins, then use 3% povidone iodine stock solution to burn the corneal ulcer, 0.
9% normal saline to flush the conjunctival sac and eyelash roots, and finally 0.
5% levofloxacin eye drops Nod.
(2) Wash the skin surface of the affected eyelid regularly, dry it, tear off the isolation layer covering the transparent dressing film, and help the patient to close the upper and lower eyelids with hands or cotton swabs, and then stick the film on the affected eye from the upper nose to the lower temporal Make it completely closed.
In order to avoid cross-ophthalmitis of healthy eyes and intracranial infections caused by intraocular orbital infections, eyeball enucleation should be performed when necessary.
Discuss the treatment and care of the initial stage of brainstem hemorrhage is to save lives.
Once the patient enters the recovery period, the eyelids cannot be closed due to various serious complications such as trigeminal nerve and facial nerve paralysis, loss of autonomy, etc.
, and exposed corneal ulcers occur clinically.
It is manifested by increased secretions, foreign body sensation in the eyes, mixed conjunctival hyperemia, tearing and gradual decline in vision.
Because patients with brainstem hemorrhage have often used a large number of broad-spectrum antibacterial drugs and glucocorticoids in the process of treating systemic diseases, and exposed corneal ulcers lack effective drug treatment [3], the conventional treatment effect is not good.
At the same time, because such patients are mostly seen in other related departments such as neurology/surgery or ICU.
However, the medical staff of the relevant clinical departments did not pay enough attention to the early judgment and attention to exposure keratitis, which caused the patient to seek help from the ophthalmology consultation only after the corneal ulcer was more serious.
In addition, the patient's general condition is poor, unable to actively cooperate with treatment, and it is even more difficult to receive upper and lower eyelid sutures and keratoplasty.
If improperly treated corneal ulcers are often accompanied by survival, it will not only reduce the patient's quality of life, but also waste medical resources due to repeated long-term dressing changes.
Put forward higher requirements for clinicians [4].
The main purpose of the treatment of exposed corneal ulcer is to protect the exposed ulcer surface, reduce the formation of corneal neovascularization, reduce the number of bacteria in the conjunctival sac, form a protective wet room, reduce the occurrence of dry eye, and promote the surface of the corneal ulcer as much as possible.
heal. Reference materials: [1] Wu Jiang, Jia Jianping, Cui Liying.
Neurology [M].
Beijing: People's Medical Publishing House, 2011: 171.
[2] Tang Yuhua.
Nursing guidance and health education for acute hemorrhagic conjunctivitis[J].
Nursing practice And Research, 2009, 6 (21): 54-56.
[3] He Shouzhi.
Clinical Ophthalmology [M].
Tianjin: Tianjin Science and Technology Press, 2002: 830-831.
[4] Liu Ming.
Core competence of specialist nurses Discussion on the framework[J].
Chinese Nursing Management, 2009, 9:27-29.
Brainstem hemorrhage (brainstem hemorrhage) accounts for about 10% of clinical cerebral hemorrhage cases.
Although the incidence is not high, it has a rapid onset, a dangerous condition, and a poor prognosis.
It has the highest mortality and disability rate among all cerebrovascular diseases, and its prognosis The worst type of cerebrovascular disease.
The overwhelming majority are pons hemorrhage, caused by the rupture of the pontine branch of the basilar artery, occasionally hemorrhage in the midbrain and bulbar hemorrhage are extremely rare.
The clinical manifestations of brainstem hemorrhage are mostly sudden headache, dizziness, vomiting, diplopia, different ocular axes, lateral vision paralysis, cross paralysis or hemiplegia, quadriplegia, etc.
When massive hemorrhage (>5ml) occurs, the hematoma spreads to the base and tegmental part of the pons, and the patient quickly enters into disturbance of consciousness and even death [1].
The main complications include pulmonary infection, upper gastrointestinal bleeding, dysphagia, water and electrolyte imbalances, central high fever, deep vein thrombosis, and seizures, which should be identified and dealt with as soon as possible.
However, patients with brainstem hemorrhage can also be complicated by exposure keratitis.
If it cannot be detected in time and treated actively and effectively, the severe cases may face the risk of removal of the affected side of the eyeball.
This article conducts a systematic analysis of this complication, so that everyone has a better understanding and scientific treatment.
Case sharing patient, male, Fang Mohua, 38 years old.
On January 10, 2021, he was rushed to our hospital for "sudden loss of consciousness for half an hour".
He has a history of hypertension for several years without formal diagnosis and treatment.
Emergency physical examination: appearance of acute critical illness, moderate coma, snoring breathing, bilateral pupils with equal circles, diameter of about 2.
5 mm, slow reflection of light, inability to close left eye cleft, right angle of mouth, bilateral limb paralysis (left The muscle strength of the lateral limbs is level II to III, and the muscle strength of the right limb is level 0), and the heart, lungs, and abdomen are normal. A plain CT scan of the skull revealed a patchy high-density shadow in the brainstem, with a larger section of about 24mm×10mm, with a clear boundary.
In view of the serious condition, it is recommended to transfer to a higher-level hospital for further diagnosis and treatment, and perform "stereotactic brainstem hematoma removal + cerebrospinal fluid drainage and replacement surgery" on January 13.
After being transferred back to our hospital on March 24, it was found that the patient's left eyeball conjunctiva was hyperemia and edema, and the cornea was foggy and turbid.
Please consider exposure keratitis of the left eye and oculomotor palsy of the left eye after the ophthalmology consultation.
In addition, two other patients with brainstem hemorrhage admitted recently also had similar manifestations.
Figure 1: The patient’s imaging findings and signs.
Brain stem anatomy.
The brain stem is a small part of the central nervous system located between the diencephalon and the spinal cord.
From top to bottom, it consists of the midbrain, pons, and medulla oblongata.
In addition to the olfactory nerve and optic nerve of the cranial nerves, the cranial nerves from Ⅲ to Ⅻ all enter and exit the brainstem.
Among them, the trigeminal nerve is located on the ventral lateral surface of the middle part of the pons, and the branch of the ophthalmic nerve splits from the supraorbit into the orbit, innervating the eyelid, cornea, lacrimal gland and forehead skin.
The main nucleus of the lateral oculomotor nerve is the largest, containing clusters of large neurons, innervating the levator eyelid muscle, medial rectus muscle, superior rectus muscle, inferior rectus muscle and inferior oblique muscle.
Figure 2: Brainstem anatomy, derived from network pathogenesis-related mechanisms.
The cornea is located at the forefront of the eyeball, occupying 1/6 of the surface of the eyeball.
The surface is extremely smooth, transparent and shiny.
There are no blood vessels.
Its nutrition depends on the vascular network and front of the peripheral corneal limbus.
Diffusion and penetration of glucose, oxygen and other substances contained in the tear film and subsequent aqueous humor.
Therefore, the cornea has a slow metabolism and poor resistance.
Once it is damaged, the inflammatory response is obvious, and its self-repair ability is low.
Patients with brainstem hemorrhage often lead to incomplete closure of the upper eyelid due to coma and facial paralysis, and the eye branch of the trigeminal nerve is dull, leading to corneal dryness, inflammatory infiltration, and even corneal ulcers and corneal perforation.
It has been found in clinical practice that exposure keratitis complicated by this disease is generally severely damaged.
Clinical manifestations and treatment mainly include eye pain, redness, irritation, foreign body sensation and sticky secretions, multiple punctate exfoliation of the corneal epithelium, and some patients have severe clinical symptoms, recurrent episodes and a long course of disease [2].
Treatment: (1) First, clean the eye secretions, then massage the eyelid margins, then use 3% povidone iodine stock solution to burn the corneal ulcer, 0.
9% normal saline to flush the conjunctival sac and eyelash roots, and finally 0.
5% levofloxacin eye drops Nod.
(2) Wash the skin surface of the affected eyelid regularly, dry it, tear off the isolation layer covering the transparent dressing film, and help the patient to close the upper and lower eyelids with hands or cotton swabs, and then stick the film on the affected eye from the upper nose to the lower temporal Make it completely closed.
In order to avoid cross-ophthalmitis of healthy eyes and intracranial infections caused by intraocular orbital infections, eyeball enucleation should be performed when necessary.
Discuss the treatment and care of the initial stage of brainstem hemorrhage is to save lives.
Once the patient enters the recovery period, the eyelids cannot be closed due to various serious complications such as trigeminal nerve and facial nerve paralysis, loss of autonomy, etc.
, and exposed corneal ulcers occur clinically.
It is manifested by increased secretions, foreign body sensation in the eyes, mixed conjunctival hyperemia, tearing and gradual decline in vision.
Because patients with brainstem hemorrhage have often used a large number of broad-spectrum antibacterial drugs and glucocorticoids in the process of treating systemic diseases, and exposed corneal ulcers lack effective drug treatment [3], the conventional treatment effect is not good.
At the same time, because such patients are mostly seen in other related departments such as neurology/surgery or ICU.
However, the medical staff of the relevant clinical departments did not pay enough attention to the early judgment and attention to exposure keratitis, which caused the patient to seek help from the ophthalmology consultation only after the corneal ulcer was more serious.
In addition, the patient's general condition is poor, unable to actively cooperate with treatment, and it is even more difficult to receive upper and lower eyelid sutures and keratoplasty.
If improperly treated corneal ulcers are often accompanied by survival, it will not only reduce the patient's quality of life, but also waste medical resources due to repeated long-term dressing changes.
Put forward higher requirements for clinicians [4].
The main purpose of the treatment of exposed corneal ulcer is to protect the exposed ulcer surface, reduce the formation of corneal neovascularization, reduce the number of bacteria in the conjunctival sac, form a protective wet room, reduce the occurrence of dry eye, and promote the surface of the corneal ulcer as much as possible.
heal. Reference materials: [1] Wu Jiang, Jia Jianping, Cui Liying.
Neurology [M].
Beijing: People's Medical Publishing House, 2011: 171.
[2] Tang Yuhua.
Nursing guidance and health education for acute hemorrhagic conjunctivitis[J].
Nursing practice And Research, 2009, 6 (21): 54-56.
[3] He Shouzhi.
Clinical Ophthalmology [M].
Tianjin: Tianjin Science and Technology Press, 2002: 830-831.
[4] Liu Ming.
Core competence of specialist nurses Discussion on the framework[J].
Chinese Nursing Management, 2009, 9:27-29.
