Hemorrhagic Stroke Flashcards
Hemorrhagic Stroke
-20% of all strokes
Cerebral Hemorrhage
- subarachnoid hemorrhage
- intracerebral hemorrhage
- epidural hemorrhage
- subdural hemorrhage
Subarachnoid Hemorrhage
-bleeding into the subarachnoid space accounts for ~50 of cerebral hemorrhages
Parenchymal hemorrhage
-bleeding into the substance of the brain accounts for ~50 of cerebral hemorrhages
Etiologic Diagnosis: Hemorrhagic Stroke
- Berry aneurysm
- vascular malformation
- traumatic
- mycotic aneurysm
- HTN
- tumor
- bleeding diatheses
- anticoagulant complication
- congophilic angiopathy
- vasculitis
- illicit drug use
Aneurysmal Subarachnoid Hemorrhage
-80% of SAH caused by rupture of berry or saccular aneurysm
Berry Aneurysms
- 20% with aneurysm 5mm bleed at a rate of 1-3%/year best treated surgically or intravascular coils
- 30,000 americans suffer a ruptured berry aneurysm yearly
Risk Factors for Subarachnoid (SAH) Hemorrhage
- tobacco use
- ethanol abuse
- HTN
- oral contraceptives
- stimulant drugs (cocaine)
- low cholesterol
- genetics (polycystic kidneys, Marfan’s syndrome)
Natural History of Subarachnoid (SAH) Hemorrhage
-10-15% die prior to ER
-25% die during next 3 months
~40% survivors have neurologic sequelae
Symptoms of Subarachnoid (SAH) Hemorrhage
- sudden, severe headache “worst of my life”
- rapid loss of consciousness in some but not all patients
- neck stiffness/pain, photophobia, phonophobia
- Nausea/vomiting
- focal neurologic signs frequently minimal or absent
Signs of Subarachnoid Hemorrhage
-abnormal vital signs (elevated BP, arrhythmias)
-focal neurologic signs subtle or absent III nerve paresis (IC/PCom) aneurysm
Paraparesis - ACA aneurysm
Hemiparesis - MCA aneurysm
-Meningeal signs - usually present but may be subtle or delayed
-retinal hemorrhages
CT in Subarachnoid Hemorrhage
- most important diagnostic test to reveal blood in subarachnoid space or brain
- location of blood helps localize site of reupured aneurysm
- CT may be - if bleeding is slight or if CT delayed for several days
- CT - and you suspect SAH, perform lumbar puncture to rule out bleeding
Lumbar Puncture in Subarachnoid Hemorrhage
- if CT - for blood and SAH is suspected, perform lumbar puncture
- delay the LP for approximately 4 hrs after symptom (headache) onset
- if CSF appears bloody/discolored, immediately centrifuge it & examine for xanthochromia
Neuroradiology in Subarachnoid Hemorrhage
- MRI will reveal larger (>5mm) aneurysms
- gold standard is 4-vessel digital subtraction arteriography (DSA) for demonstrating one or more aneurysms (multiple could be polycystic kidney disease)
Treatment for Subarachnoid Hemorrhage
-definitive therapy for berry aneurysm is a combination of interventional radiology to coil some aneurysms with or without surgical clipping of the aneurysm
