Haemorhagic Stroke

Question 1

True or false: The majority of strokes are haemorrhagic.

Answer 1

False

Approximately 15% of strokes are haemorrhagic.

Question 2

True or false: management options for haemorrhagic and ischaemic strokes differ radically

Answer 2

True

Question 3

True or false: Haemorrhagic strokes can reliably be diagnosed clinically

Answer 3

False.

CT or MRI are essential in diagnosis. There are many ‘stroke mimics’ and you also need to determine whether the patient has an ischaemic or haemorrhagic stroke.

Question 4

True or false: Stroke is the number one cause of death in most resource-rich countries.

Answer 4

False.

Stroke is the third most common cause of death in most resource-rich countries.

Question 5

True or false: Men have a higher incidence of haemorrhagic stroke than women.

Answer 5

True

Question 6

True or false: Asians have a higher rate of intracerebral haemorrhage compared with other ethnic groups.

Answer 6

True

Question 7

A patient suffering from haemorrhagic stroke may present with which signs and symptoms?

Answer 7

Develop over seconds or minutes:

• Reduced GCS
• Headache, neck stiffness, and photophobia (meningism)
• Nausea and vomiting
• Severe headache
• Ataxia
• Aphasia (fluent or nonfluent)

Question 8

How would you investigate a suspected stroke?

Answer 8

Brief history and neurological examination.

Immediate CT/MRI if any apply:

• Within 4.5 hours of onset
• Reason to suspect haemorrhage (anticoagulation, known tendency)
• Reduced GCS
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness or fever
• Severe headache at onset of symptoms

CT/ MRI within 24 hours of symptom onset if no indication for immediate imaging.

Discuss with stroke team

Question 9

What additional investigations would you do for a ?stroke after imaging was clear or inconclusive?

Answer 9

Bloods: FBC, UEs, glucose, cholesterol, coagulation

MRI

Carotid USS

ECG (exclude AF)

Repeat imaging as early haemorrhages and infarcts may not be seen until they have time to progress.

Question 10

True or false: A patient waiting for CT with suspected stroke should be given 300mg Aspirin if seen within 4.5 hours of symptom onset.

Answer 10

False

Only give aspirin AFTER haemorrhage has been ruled out by CT and only if symptoms still persist.

Question 11

How would you manage a CT-confirmed intracranial haemorrhage?

Answer 11

Discuss with neurosurgery and transfer to neurosurgical ICU.

• Drugs to prevent vasospasm (nimodipine)
• Correct coagulopathies
• Control HTN with IV antihypertensives (labetalol, nicardipine)
• Control glucose
• Monitor for raised ICP
• Consider surgical intervention to prevent rebleed (clipping and coiling)

Question 12

What is a typical presentation of subarachnoid bleed?

Answer 12

• Thunderclap headache
• Reduced GCS
• Photophobia
• Pulsating pain towards occiput

Question 13

What is the usual cause of a subarachnoid bleed?

Answer 13

Berry aneurysm in circle of Willis

Question 14

Why should you prescribe stool softener for patients with haemorrhagic strokes?

Answer 14

Straining while on the toilet may cause further bleeding/rebleed.