Hemorrhagic Stroke

Question 1

Definition of Hemorrhagic Stroke

Answer 1

An acute neurological deficit caused by cerebrovascular aetiology

Question 2

Epidemiology of hemorrhagic stroke

Answer 2

Stroke is the 3rd most common cause of death. Ischemic stroke = 85% of cases, haemorrhagic strokes = 15%.
3/4 are intracerebral haemorrhage. 1/4 are subarachnoid haemorrhages.
Men have a higher incidence than women
Increased rate in asians for intracerebral haemorrhage

Question 3

Aetiology of haemorrhagic stroke

Answer 3

Primary: Cerebrovascular changes induced by long standing HTN. Cerebral amyloid angiopathy (CAA) accounts for a significant number of primary hemorrhagic stroke.It is caused by beta amyloid deposition in the walls of medium and small sized arteries restricted to the brain cortex + cerebellum. HTN can cause hemorrhage in any intracranial location. Chronic HTN can also result in cerebral microbleeds caused by damaged small vesicles, yet these are typically within the deeper brain structures.

Secondary intracerebral hemorrhage:
Cerebral infarction or cerebral tumor with hemorrhage into diseased tissue. Sympathomimetic drugs of abuse such as cocaine and amphetamine.
Brain AV malformation - benign, natural hx.

Question 4

Pathophysiology of hemorrhagic stroke

Answer 4

Intracerebr, al haemorrhage is caused by vascular rupture with bleeding into the brain parenchyma resulting in a primary mechanical injury to brain tissue. Expanding haematoma may shear additional neighbouring arteries - resulting in further bleeding and haematoma expansion. May increase intracranial pressure,decrease in cerebral perfusion, secondary ischemic injury and even cerebral herniation. Consequence of haematoma growth: haemorrhage may rupture into the subarachnoid space or intraventricular space

Primary spontaneous:
- idiopathic
-anticoagulation
Secondary:
- identifiable vascular formation 
-medical or neurological diseases that impair coagualtion or promote vascular rupture (cerebral infarction or tumour, sympathomimetic drugs of abuse, haem, malignancies)

Question 5

Hx and Exam for hemorrhagic stroke

Answer 5

Common:

1. Neck stiffness
2. Hx of AF
3. Hx of liver disease
4. Visual changes
5. Photophobia
6. Sudden onset
7. Altered sensation
8. Headache
9. Weakness
10. Sensory Loss
11. Aphasia
12. Dysarthria
13. Ataxia

Uncommon:

1. Hx of haem disorder
2. Vertigo - seen in cerebellar hemorrhage
3. N+V
4. Altered level of consciousness/coma
5. Confusion
6. Gaze paresis

Question 6

Risk factors for hemorrhagic stroke

Answer 6

Strong:
HTN 
Advanced age
Male
Asian/black/hispanic
FHx of haemorrhagic stroke
Haemophilia
Anticoagulation 
Illicit sympathomimetic drugs 
Cerebral amyloid angiopathy
Autosomal dominant mutations in COL4A1 gene
Hereditary haemorrhagic telangiectasia 
Autosomal dominant mutation in KRIT1 gene, CCM2 gene, PDCD10 gene
Vascular malformations 
Moyamoya disease - affects paediatric patients. Associated with parenchymal + intraventricular haemorrhage. 

Weak:
Smoking
NSAIDs
Diabetes mellitus
Heavy alcohol abuse
Sympathomimetic medications
Cerebral vasculitis
Thrombocytopenia 
Leukaemia

Question 7

Investigations for hemorrhagic stroke

Answer 7

1. Non-infused head CT = hyperdense lesion
2. Chemistry panel = normal
3. FBC = usually normal
4. Clotting test = usually normal
5. ECG = signs of myocardial ischemia cerebral T waves
6. Platelet function test = abnormal platelet aggregation
7. Urine drug screen = positive or negative
8. Pregnancy test in women of childbearing age = positive or negative
9. LFTs = deranged
10. ICH score = score for prognosis after early onset of intracerebral haeamorrhage

Question 8

Management for hemorrhagic stroke

Answer 8

Initial: presumed haemorrhagic stroke
1st line: neurosurgical + neurocritical care evaluation
PLUS admission to neuroscience ICU or stroke unit, airway protection, aspiration precautions

Acute: non-cerebellar bleed: stable and alert
1st line: neurosurgical + neurocritical care evaluation
PLUS admission to neuroscience ICU or stroke unit, supportive care, BP control, DVT prophylaxis, anti-pyretic measures, correction of coagulopathy

Non-cerebellar bleed: decompensating
1st line: neurosurgical + neurocritical care evaluation
PLUS admission to neuroscience ICU or stroke unit, supportive care, BP control, surgery, supportive mx and/or external ventricular drainage, anti-pyretic measures, anticonvulsants, correction of coagulopathy

<3cm cerebellar bleed: alert
1st line: neurosurgical + neurocritical care evaluation
PLUS admission to neuroscience ICU or stroke unit, supportive care, BP control, anti-pyretic measures, correction of coagulopathy

> 3cm cerebellar bleed or drowsy/unstable
1st line: neurosurgical + neurocritical care evaluation
PLUS admission to neuroscience ICU or stroke unit, supportive care, DVT prophylaxis, surgery, BP control, antipyretic measures, correction of coagulopathy