27B Hemorrhagic Stroke

Question 1

______ and ______ hemorrhages each account for 50% of cerebral hemorrhages.

Answer 1

Subarachnoid, parenchymal

Question 2

Subarachnoid aneurysms are MC caused by:

Answer 2

rupture of saccular (berry) aneurysms

Question 3

What causes berry aneurysms?

Answer 3

developmental defects in the blood vessel wall that tend to enlarge with time

Question 4

MC locations for berry aneurysms?

Answer 4

Ant cerebral (30%)
int carotid (30%)
middle cerebral (25%)
basilar (10%)
post cerebral (5%)

(Ant>post)

Question 5

Risk factors for subarachnoid hemorrhage?

Answer 5

1. tobacco
2. ETOH
3. HTN
4. oral contraceptives
5. stimulant drugs
6. low cholesterol
7. genetics (Marfan, polycystic kidney)

Question 6

Symptoms of SAH?

Answer 6

1. sudden severe HA (“worst”)
2. rapid loss of consciousness (some pts)
3. neck stiffness, pain
4. photophobia and phonophobia
5. NV
   (focal neurologic signs minimal or absent)

Question 7

What symptoms follow the rupture of a berry aneurysm within hours?

Answer 7

neck stiffness, pain

photophobia and phonophobia

Question 8

What causes the symptoms that follow the rupture of a berry aneurysm?

Answer 8

irritation and inflammation of the meninges secondary to the breakdown products of RBC lysis

Question 9

Signs of SAH?

Answer 9

1. abn vitals (HTN, irreg HR)
2. subtle or delayed meningeal signs
3. retinal hemorrhages
4. if present, subtle focal deficits

Question 10

What causes arrythmia associated with SAH?

Answer 10

RBC breakdown products that irritate brainstem centers regulating heart rate.

Question 11

CN III paresis resulting in a dilated pupil and ophthalmoparesis is consistent with an aneurysm at:

Answer 11

junction of the internal carotid and posterior communicating arteries

Question 12

Paraparesis (bilateral leg weakness) suggests an aneurysm of:

Answer 12

anterior cerebral artery

Question 13

Hemiparesis is consistent with an aneurysm of:

Answer 13

middle meningeal artery

Question 14

Most helpful noninvasive diagnostic test to identify a subarachnoid hemorrhage

Answer 14

CT

Question 15

The amount of blood and its location help determine:

Answer 15

• site of the berry aneurysm

- likelihood of a delayed complication called “vasospasm”

Question 16

CT scan may be negative in a patient with a ruptured berry aneurysm, especially if:

Answer 16

bleeding is slight or if the scan is delayed for a day or more after the rupture

Question 17

What test should you do if the CT is negative, but you still suspect a SAH?

Answer 17

LP, delayed 3-4h after the onset of HA

(allow time for some of the red blood cells in the subarachnoid space to lyse and release hemoglobin into the spinal fluid, centrifuge to confirm)

Question 18

Only method to 100% rule out a subarachnoid bleed

Answer 18

LP

Question 19

What is xanthochromia?

Answer 19

yellow discoloration that results from the break down of hemoglobin; takes a day or more after rupture of the an aneurysm

Question 20

Imaging performed after SAH confirmed?

Answer 20

gold standard = 4-vessel digital subtraction arteriogram

alternative = MRI (for >5mm)

Question 21

Trx for SAH?

Answer 21

1. coil (through an intra-arterial catheter to cause the aneurysm to clot and seal itself)
2. metal clip at the neck of the aneurysm
3. combo of both

Question 22

MC causes for parenchymal hemorrhage?

Answer 22

1. head trauma
2. HTN
3. AV malformations

Question 23

What are Charcot Bouchard aneurysms?

Answer 23

microaneurysms caused by chronic elevation of the blood pressure –> injury to small cerebral blood vessels

Question 24

Where do Charcot Bouchard aneurysms develop?

Answer 24

small, penetrating microvessels located in the basal ganglia, thalamus, pons, and cerebellum

(**MC sites of parenchymal hemorrhage)

Question 25

Trx for AV malformations?

Answer 25

occlusion with coils, followed by surgical removal or obliteration with use of a gamma (knife) x-ray device

Question 26

Trx for HTN or traumatic parenchymal hemorrhage?

Answer 26

1. correct any bleeding abn
2. decr BP to <130
3. monitor for and treat incr ICP