Haemorrhagic stroke Flashcards

1
Q

haemorrhagic stroke definition

A

haemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in

  • intraparenchymal haemorrhage
  • subarachnoid haemorrhage
  • intraventricular haemorrhage
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2
Q

aetiology of haemorrhagic stroke

A
  1. Primary - spontaneous and absence of vascular malformation
  2. Secondary - identifiable vascular malformation/complication of medical and neurological disease
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3
Q

key diagnostic factors of haemorrhagic stroke

A
  1. neck stiffness / photophobia / visual changes
  2. history of liver disease
  3. altered sensation / sensory loss
  4. headache - insidious onset + gradually increasing intensity
  5. unilateral muscle weakness
  6. dysarthia
  7. aphasia
  8. ataxia
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4
Q

most common symptoms of intracerebral haemorrhage

A
  1. Limb weakness
  2. Paraesthesias or numbness
  3. Dizziness
  4. Vertigo
  5. Nausea/vomiting
  6. Speech difficulty
  7. Visual loss or double vision
  8. Confusion
  9. Headache.
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5
Q

risk factors of haemorrhagic stroke

A
  1. hypertension
  2. advanced age
  3. haemophilia
  4. cerebral amyloid angiopathy
  5. anticoagulation medication
  6. Vascular malformations - AVF, cavernous malformations
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6
Q

signs to differentiate ischaemic vs intracerebral haem

A

ICH is more commonly assoc with;

  1. reduced levels of consciousness
  2. increased intracranial pressure signs such as anausea and vomitting
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7
Q

initial evaluation of ICH

A
  1. Evaluate airway - breathing, pulse, circulation ( vascular access + BP checked )
  2. Brief history of stroke symptoms + streamlined neuro exam
  3. rapid physical assessment tool for stroke signs - NIH stroke score/ICH score
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8
Q

Investigations to order (first line)

A
  1. Non infused head CT - differentiates haemorrhagic from ischaemic stroke
  2. chemistry panel - hypoglycaemia + electrolyte disturbances
  3. FBC - exclude thrombocytopenia
  4. Clotting tests / platelet function test
  5. ECG - Myocardial ischaemia can complicate a stroke/
    - Large inverted t waves : suggest ECG changes of cerebral origin
  6. LFTs
  7. ICH score
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9
Q

Second line investigations to consider

A
  1. CT angiography/venography - rules out aneurysm/ AVM and venous thrombosis
    - recc in all pts < 45
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10
Q

differentials

A
  1. Ischaemic stroke
  2. Hypoglycaemia
  3. hypertensive encephalopathy
  4. Complicated migraine
  5. seizure disorder
  6. conversion + somatisation disorder
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11
Q

IS vs ICH

A
  • Symptoms occur suddenly.
  • In ischaemic stroke, patients do not exhibit gastrointestinal symptoms (N/V) or headache typically.
  • Acute haemorrhage appears bright due to hyperattenuation of the x-ray beams in CT scan.

In contrast, ischaemic infarct appears as hypoattenuation (darkness), although may not appear for many hours after stroke onset.

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12
Q

Hypertensive encephalopathy vs ICH

A

Hypertension significantly above patient’s baseline blood pressure associated with headache, decreased consciousness or cognitive abnormalities, visual changes or loss, and signs of increased intracranial pressure. Less frequently these patients present with focal abnormalities in the neurological examination.

Cerebral oedema on CT or MRI. Certain patients present characteristic changes in the posterior aspect of the brain.

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13
Q

hypoglycaemia vs ICH

A

Sweating, tremor, hunger, confusion, and ultimately a decreased level of consciousness.

May have known history of diabetes mellitus and insulin use or medical conditions associated with hypoglycaemia.

Low serum glucose on blood chemistry.

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14
Q

Manage`ment - OVERALL

A
  1. Admission in ICU / Stoke unit for 24 hour surveillance
    - Airway protection to those with reduced consciousness/ endotracheal intubation for airway protection is recommeded
  2. Supportive care
    - Supplemental oxygen if oxygen sat < 94%
    - Aspiration precaution
    - treat hyperglycaemia
    - Blood pressure control
    - DVT prophylaxis
    - Blood pressure control
    - Antipyretic measures
    - Correct coagulopathy
  3. Potential Surgical intervention
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15
Q

Surgical intervention

A
  1. surgery in non cerebellar bleeds ( ie. in cerebrum + surrounding structures ) is controversial and no evidence to suggest it improves outcomes
  2. Cerebellar haemorrhage can be lifesaving if
    - patient is drowsy/loss of consciousness
    - haemorrhage size >3cm
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16
Q

Raised ICP management - ‘patients with intracranial haemorrhage are at risk of developing raised ICP from expanding haematoma/oedema/hydrocephalus/

A
  1. head of bed elevation to 30 degrees
  2. Mild hyperventilation - tracheal intubation and mechanical ventilation
  3. Analgesia + sedation
  4. External ventricular drainage of csf
  5. osmotic therapy - mannitol / hypertonic saline
  6. corticosteroids should not be used !! ( cause more compl )
17
Q

Aspiration precautions

A
  1. swallowing impairment is common in stroke and associated with increased risk of aspiration pneumonia
  2. nil by mouth + isotonic fluids via nasogastric tubes
18
Q

Seizure management

A
  1. seizures affect 22% of stroke victims
  2. prophylactic use of anticonvulsants have not been proven to be effective
  3. anticonvulsants should be used to treat clinical seziures
19
Q

Management of anticoagulated patients

A

ALL PATIENTS WITH INTRACEREBRAL BLEED SHOULD BE GIVEN VITAMIN K INTRAVENOUSLY

  1. correct hypocoaguble state - administration of anticoagulants should be ceased and antidotes administered
  • Antidote for patients on warfarin INR > 1.5 :
    = phytomenadione ( Vitamin K) + Fresh frozen plasma/ 4 factor prothrombin concentrate
  • Antidote for patients on heparin :
    = Protamine sulfate + platelet transfusion
  • -
20
Q

Treatment of fever

A
  • The presence of fever is common after intracerebral haemorrhage, especially when associated with intraventricular haemorrhage.
  • The duration of fever has been associated with worse outcomes and has been established as an independent prognostic factor.
    1. Antipyretic - paracetamol recommended
21
Q

Treatment of hyperglycaemia

A
  • Untreated hyperglycaemia is independently associated with poor prognosis in intracerebral haemorrhage;
  • consequently, prompt glucose correction is recommended despite a lack of evidence for improving outcomes.
22
Q

DVT prophylaxis

A
  1. Complications due to venous thromboembolism are very common in critically ill patients with neurological injury due to ;
    - increased venous stasis from paralysis
    - prolonged coma
  2. The risk of venous thromboembolism may be higher in patients with haemorrhagic stroke as compared with patients with ischaemic stroke
  3. Early mobilisation of patients is recommended
  4. low-dose unfractionated or low molecular weight heparin may be considered >48 hours after onset as long as there is no evidence of continued bleeding
23
Q

Blood pressure control

A
  • Elevated BP could promote further bleeding
  • Requires treatment if systolic BP > 180
  1. Labetalol - ( 5 - 20mg over 2 mins and 10-20mg every 10 minutes )
    or
  2. Nicardipine - 5mg an hour intravenously
24
Q

complications of haemorrhagic stroke

A
  1. DVT
  2. Infections - aspiration pneumonia
  3. Seizures
  4. Hydrocephalus