Hemorrhagic Stroke Flashcards
What are 4 signs of elevated ICP?
- Elevated BP, often extremely high (in 90% of patients)
- Headache (40%) – headache may be absent in ICH
- Vomiting( approx. 50%) especially if hemorrhage is within cerebral hemisphere
- Sudden onset of neurologic deficits
What is a hemorrhagic stroke?
- Stroke that occurs when there is bleeding into the subarachnoid space or the brain parenchyma
- Pre-hospital management is geared towards airway maintenance, cardiovascular support and rapid transport to nearest acute stroke care hospital
- Neuroimaging with brain CT or MRI is mandatory to confirm diagnosis and to exclude stroke mimics as possible causes
What are the initial goals of treatment for patients with hemorrhagic stroke?
Initial goals of treatment include:
- Prevention of hemorrhage extension
- Prevention and management of secondary brain injury
- Prevention and management of other neurologic and medical complications
What causes a hemorrhagic stroke?
- HTN ( Most common etiology of spontaneous hemorrhagic stroke in adults)
- Use of anticoagulants or thrombolytics
- Use of illicit street drugs (cocaine)
- Heavy use of alcohol ( 3 x higher risk of ICH than normal)
What are the 2 types of hemorrhagic stroke?
1. Subarachnoid hemorrhage (SAH)
- Ruptured saccular aneurysm (85%)
- Arteriovenous malformation (8%)
- Cryptogenic
2. Intracerebral hemorrhage (ICH)
- Usually associated with HTN
What are the clinical manifestations associated with SAH?
- Sudden headache “worse headache of my life”; intense severity; radiates into posterior neck and worsening by any head or neck movement; ‘thunderclap headache’
Hunt and Hess grading classification scale
- Grade 1: asymptomatic, slight headache (HA)
- Grade II: moderate to severe HA; stiff neck without focal signs
- Grade III: drowsy, mild focal deficit or confusion
- Grade IV: stupor, hemiparesis
- Grade V: deep coma, decerebrate posturing
Fisher grade (based on CT findings)
- Grade I: no blood detected
- Grade II: diffuse blood on CT less than 1 mm thick vertical layering
- Grade III: localized clots and/or vertical layering 1 mm thing or more
- Grade IV: intracerebral or intraventricular clot with diffuse or no SAH
What diagnostic tests do you do to diagnose a subarachnoid bleed?
- CT head without contrast to differentiate between ischemic and hemorrhagic stroke
- CTA: Aneurysms less than 3 mm in size are unreliably demonstrated on CTA; depending upon site, size and CT scan quality- variable results
-
LP if CT scan is negative and suspicion is High
- Contraindicated if expanding mass is present
- Must perform funduscopic exam prior to performing to r/o papilledema
- CSF if uniformly grossly bloody is indication of SAH, 103-106 RBCs/mm
- Opening pressure increased
- Xanthochromia present – yellowish discoloration of CSF produced by blood breakdown products
- Cerebral angiogram: utilized to determine source of bleed, presence of aneurysms and possible treatment; vasospasm may occur; should be performed once patient is stabilized
How do you manage a patient with SAH?
ABC’s: Airway, Breathing, Circulation first – Intubate to protect airway if needed
External ventricular drain placement if hydrocephalus seen on CT scan
Cardiac Monitoring- ICU
Strict best rest, quiet environment
Reversal of anticoagulation:
If ICH occurred on warfarin, aggressive use of vitamin K, FFP may be necessary- consult hematology
Protamine sulfate is recommended for urgent treatment of patients with heparin associated ICH
Avoid NSAIDs due to bleeding risks
Have patient avoid all forms of straining and exertion
Stool softeners and laxatives – docusate 100-200mg po bid
Seizure prophylaxis:
Up to ¼ patients with SAH develop seizures
Short term seizure prophylaxis is used
Commonly used meds:
Dilantin, 100mg IV q 8 hours, titrate to blood level 10-20mcg/mL for 7 days
Levetiracetam (Keppra), 500mg IV or po bid for 7 days
Anti-Hypertensive management:
Acute HTN can lead to aneurysm re-rupture and should be aggressively managed
Maintain SBP < 160mmHg
Consider IV titratable nicardipine drop OR
Labetalol 10mg IVP OR
Hydralazine 10-20mg IVP if patient is bradycardic
Cerebral edema: reduce with mannitol and or hypertonic saline solutions
Mannitol, 0.25-1 gm/kg IV every 4-6 hours
Saline 3% solution, loading dose of 250-300mL IV over 60 minutes, followed by continuous infusion titrated to treatment goals, including 145-155 mEq/L and serum osmolality of 310-320 mOsm/L
Surgical clipping or endovascular coiling should be performed as early as possible. Choice of therapy is dependent upon size and location of aneurysm and experience of provider
Coil embolization and/or stent placement for ruptured aneurysm is performed by neurointerventionalist or neuroradiologist
May cause vasospasm (30%) usually resolves within 21 days
Symptoms include confusion, decreased LOC, localizing neuro deficits, headache, increased ICP, cerebral infarction can occur
Calcium channel blockers (nifedipine) may be used to treat cerebral blood vessel spasm after SAH from ruptured cerebral aneurysm (60mg po/ngt) q 4 hours for 3 weeks).
If symptomatic vasospasms occur, patient is usually treated with IVF loading:
Goal of hematocrit – 30%
Monitor cardiac output and CVP
Goal is to optimize the low shear rate viscosity of the whole blood and to ensure CPP is adequate to restore regional cerebral blood flow in perfusion areas beyond vasospastic vessels
Re-bleeding:
Unpredictable- may originate from fibrinolysis of clot at site of ruptured aneurysm; often occurs days 2 - 19
40% of patients re-bleed; ½ are fatal
Neurologic deterioration is usually abrupt
Stat repeat CT and LP to confirm re-bleed
Fever:
Most common medical complication after SAH
Presence of fever is noninfectious- associated with severity of injury, amount of hemorrhage, development of vasospasm
Marker of systemic inflammatory state
Fever often associated with worse cognitive outcomes
Aggressive fever management is recommended
What are the 5 things to manage for patients with ICH?
1. ABCs - Intubate if needed
2. BP Management
- Pt. who presents with SBP between 150-220mmHg, goal is SBP 140mmHg
- Pt. who has SBP > 220mmHg gets IV BP medication (Cardene/labetalol/esmolol). Optimal goal of SBP is 140-160 mmHg
- Maintain MAP > 90, if it falls start vasopressors
3. ICP monitoring
- Maintain ICP < 20 mmHg
- Invasive monitoring of ICP warranted for patients with Glasgow coma scale (GCS) < 8, evidence of transtentorial herniation or significant intraventricular hemorrhage or hydrocephalus.
4. Seizure PPX
- Dilantin or Keppra
5. Surgery
- Indicated if cerebellar hemorrhage > 3cm in diameter, OR
- Surgically accessible cerebral hematoma generally extending to within one cm of the cortical surface
- Patients with a hemorrhage > 1 cm from the cortical surface or with a GCS < 8 tend to do worse with surgical removal than with medical management
- Must assess comorbidities and age as a factor when deciding on surgical intervention.
How do you calculate CPP (Cerebral perfusion pressure)?
- CPP: Mean arterial pressure – ICP = CPP
- should be kept between 50-70 mmHg
How do you manage cerebral edema?
- Mannitol 0.25-1 gram/kg of a 20% solution given IV very 4-6 hours
- Serum osmolality should be measured BID and be kept at no greater than 320 mOsm/L
