hemorrhagic stroke Flashcards
Epidural hemorrhage location, shape
occurs between the skull and the dura, typically from an artery, especially the middle meningeal artery. These collect in a convex, or lemon shaped hematoma
Subdural hemorrhage location, shape
occurs between the dura and the thin arachnoid layer covering the brain, typically from a torn or ruptured bridging vein between the dura and the cortex. This layers like a banana (i.e. concave).
Subarachnoid hemorrhages location, causes
occur right next to the brain, underneath the arachnoid layer. Trauma is the most common cause, but everyone is more concerned with the spontaneous (i.e. non-traumatic) version from aneurysms, Arterio Venous Malformation, or other causes. An unusual occurrence, Cortical Subarachnoid Hemorrhage (cSAH) can show up with vasospasm, migraine, ischemia or without obvious cause.
Intra-parenchymal hemorrhages location
are formed blood clots which dissect into the brain. These can be anywhere. Most common in basal ganglia (putamen)
Intra Ventricular Hemorrhage
Any Hemorrhage can find it’s way into the Ventricular system
Hemorrhagic transformation
Hemorrhagic transformation of ischemic stroke beds occurs with large vessel cortical strokes. This can be asymptomatic if mild ‘bruising’ or fatal if a large formed hematoma
Intra-parenchymal hemorrhages causes and brain location
Caused by HTN, age, coagulation dz or therapeutic anticoagulation. Typical locations in Putaman, Thalamus, Pons and Cerebellum deep grey matter. Atypical locations include deep white matter, which can be from age/HTN or AVMs, aneurysm, vasculitis, bleeding disorders or hemorrhage into tumors.
Deep vs lobar intracerebral hemorrhage locations, risk factors, outcomes
Deep: aka ganglionic, putamenal, striatocapsular, hypertensive. Risk factors are HTN (2/3) and age, and non whites have higher risk. Poor outcome. Charcot-bouchard aneurysm. Lobar: frontal > parietal > occipital > temporal. Congophilic or amyloid angiopathy. Risk factors are aage, dementia, coagulation problems, HTN (1/3), whites/Asians higher risk. Tolerated well
Amyloid Angiopathy
Type of intra-parenchymal hemorrhage where patients get recurrent lobar hemorrhages that lead to progressive dementia and disability. Amyloid deposition is found in the vessels. Tolerated well by many
Subdural hemorrhage progression
The Subdural space easily tears bridging veins and causes a lower pressure, slower bleeding process. Spontaneous Subdural Hemorrhage can be relatively asymptomatic, and progress to a “Chronic Subdual Hemorrhage” which enlarges over days to months.
Epidural hemorrhage progression
The Epidural contains the Middle Meningeal Artery, which often will tear from a skull fracture creating the Epidural Hematoma. Since this is arterial or high pressure bleed, the progression can be rapid
Subarachnoid hemorrhage non-traumatic causes
aneurysmal rupture (80%), or to arteriovenous malformation (15%). Some people have “benign” peri-mesencephalic SAH that is curiously unassociated with aneurysm or AVM
Subarachnoid and intra-parenchymal hemorrhages common presentation
sudden onset of neurological deficits, but typically have associated headache, nausea, and vomiting along with a depressed level of consciousness.
non-traumatic subarachnoid hemorrhage presentation
Severe headache (“worst headache of their life”), sudden death in 1/3 ( from acute hydrocephalus or sympathetic surge and cardiac arrhythmia), Cranial nerve palsy (III), hemiparesis
Risk factors for aneurysmal hemorrhage
Genetics and smoking. NOT HTN
Intraparenchymal hematomas presentation
begin with a mild headache, deficit, maybe some nausea, and progress over a few minutes to hours adding decreased level of consciousness. hemiparesis steadily progressing into hemiplegia and a level of consciousness that steadily deteriorates into coma.
Intraparenchymal Hemorrhage risk factors
Aging, HTN, stimulant use. More common than ischemic stroke in china and Asia
Cerebral Amyloid Angiopathy risk factors
age
Cerebral Amyloid Angiopathy - how are amyloid crystals detected
birefringence lens- amyloid crystals seen in vessel walls
Classification of subarachnoid hemorrhages
Grade 1: asymptomatic or minimal headache, slight nuchal rigidity. Grade 2: moderate to severe headache, nuchal rigidity, no neurological deficity apart from cranial nerve palsy. Grade 3: drowsiness, confusion, mild focal deficit. Grade 4: stupor, moderate to severe hemiparesis, possible early decerebrate posturing. Grade 5: deep coma, decerebrate posturing
Hemorrhage management
- control BP: includes smoking cessation. 2. anti-platelet or anticoagulants: if hemorrhagic transformation is the cause. 3. Control intracranial pressure: diuresis and reduction of blood pCO2. Mannitol or loop diuretics
Subarachnoid hemorrhage treatment
- physical intervention to repair aneurysm or AVM: surgery, catheter ablation, etc. 2. Sedation. 3. Relative hypotension: reduce risk of re bleeding before surgery. 4. Nimodipine and statins: reduce ischemic damage from vasospasm from irritation of vessels by blood in subarachnoid space. 5. after surgery, hypervolemic hypertensive hemodilution (HHH), angioplasty, vasodilator meds, and other therapies can be used to reduce the effects of vasospasm.
Subdural/epidural hemorrhage treatment
Surgical decompression often needed in addition to general management of hemorrhages
