Haemorrhagic stroke Flashcards
haemorrhagic stroke definition
haemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in
- intraparenchymal haemorrhage
- subarachnoid haemorrhage
- intraventricular haemorrhage
aetiology of haemorrhagic stroke
- Primary - spontaneous and absence of vascular malformation
- Secondary - identifiable vascular malformation/complication of medical and neurological disease
key diagnostic factors of haemorrhagic stroke
- neck stiffness / photophobia / visual changes
- history of liver disease
- altered sensation / sensory loss
- headache - insidious onset + gradually increasing intensity
- unilateral muscle weakness
- dysarthia
- aphasia
- ataxia
most common symptoms of intracerebral haemorrhage
- Limb weakness
- Paraesthesias or numbness
- Dizziness
- Vertigo
- Nausea/vomiting
- Speech difficulty
- Visual loss or double vision
- Confusion
- Headache.
risk factors of haemorrhagic stroke
- hypertension
- advanced age
- haemophilia
- cerebral amyloid angiopathy
- anticoagulation medication
- Vascular malformations - AVF, cavernous malformations
signs to differentiate ischaemic vs intracerebral haem
ICH is more commonly assoc with;
- reduced levels of consciousness
- increased intracranial pressure signs such as anausea and vomitting
initial evaluation of ICH
- Evaluate airway - breathing, pulse, circulation ( vascular access + BP checked )
- Brief history of stroke symptoms + streamlined neuro exam
- rapid physical assessment tool for stroke signs - NIH stroke score/ICH score
Investigations to order (first line)
- Non infused head CT - differentiates haemorrhagic from ischaemic stroke
- chemistry panel - hypoglycaemia + electrolyte disturbances
- FBC - exclude thrombocytopenia
- Clotting tests / platelet function test
- ECG - Myocardial ischaemia can complicate a stroke/
- Large inverted t waves : suggest ECG changes of cerebral origin - LFTs
- ICH score
Second line investigations to consider
- CT angiography/venography - rules out aneurysm/ AVM and venous thrombosis
- recc in all pts < 45
differentials
- Ischaemic stroke
- Hypoglycaemia
- hypertensive encephalopathy
- Complicated migraine
- seizure disorder
- conversion + somatisation disorder
IS vs ICH
- 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.
Hypertensive encephalopathy vs ICH
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.
hypoglycaemia vs ICH
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.
Manage`ment - OVERALL
- Admission in ICU / Stoke unit for 24 hour surveillance
- Airway protection to those with reduced consciousness/ endotracheal intubation for airway protection is recommeded - Supportive care
- Supplemental oxygen if oxygen sat < 94%
- Aspiration precaution
- treat hyperglycaemia
- Blood pressure control
- DVT prophylaxis
- Blood pressure control
- Antipyretic measures
- Correct coagulopathy - Potential Surgical intervention
Surgical intervention
- surgery in non cerebellar bleeds ( ie. in cerebrum + surrounding structures ) is controversial and no evidence to suggest it improves outcomes
- Cerebellar haemorrhage can be lifesaving if
- patient is drowsy/loss of consciousness
- haemorrhage size >3cm