Stroke 2 - Haemorrhagic stroke

Question 1

Summary?

Answer 1

1. Approximately 15% of strokes are haemorrhagic
2. CT or MRI scans, with high sensitivity for intracerebral haemorrhage, are essential in diagnosis.
3. Treatments for intracerebral haemorrhage (ICH) and ischaemic stroke differ radically.
4. The primary treatment of haemorrhagic stroke involves supportive care and optimisation of intracranial haemodynamics.
5. Surgical resection of intracerebral haematomas may be of benefit in select cases, but has yet to be demonstrated as effective in clinical trials.

Question 2

Key factors?

Answer 2

neck stiffness
hx of atrial fibrillation
hx of liver disease
hx of haematological disorder
visual changes
photophobia
sudden onset
altered sensation
vertigo
nausea/vomiting
headache
weakness
sensory loss
aphasia
dysarthria
ataxia
altered level of consciousness/coma
confusion
gaze paresis

Question 3

Aetiology?

Answer 3

1. Long-standing hypertension account for the large majority of primary intracerebral haemorrhages
2. Cerebral amyloid angiopathy accounts for a significant number of primary haemorrhagic strokes in older people.
3. Cerebral amyloid angiopathy is caused by beta-amyloid deposition in the walls of medium-sized and small arteries restricted to the brain cortex, overlying leptomeninges, and cerebellum.
4. HTN and vascular malformations can cause haemorrhage in any intracranial location.

Question 4

Pathophysiology?

Answer 4

1. Vascular rupture with bleeding into the brain parenchyma.
2. Expanding haematoma may shear additional neighbouring arteries, resulting in further bleeding and haematoma expansion.
3. Haematoma growth, the haemorrhage may rupture into the subarachnoid space or the intraventricular space.
4. Mortality from intracerebral haemorrhage, high, may result from direct destruction of critical brain areas

Question 5

Classification?

Answer 5

1. Primary spontaneous:
   Idiopathic (no identifiable vascular malformations or associated diseases)

Anticoagulation.

2. Secondary
   An identifiable vascular malformation

Medical or neurological diseases that impair coagulation or promote vascular rupture (e.g., cerebral infarction or tumour, sympathomimetic drugs of abuse, haematological malignancies).

Question 6

Location of intracerebral haemorrhage?

Answer 6

1. Lobar: occurs in the cortex or subcortical white matter of the cerebral hemispheres.
2. Deep hemispheric: occurs in the supratentorial deep grey matter structures, most commonly the putamen and thalamic nuclei.
3. Brain stem: occurs mostly in the pons
4. Cerebellar: occurs mostly in the dentate nucleus.

Question 7

Primary prevention?

Answer 7

1. Lifestyle
2. Treatment of HTN and diabetes mellitus; and abstinence from smoking, use of illegal drugs, or heavy drinking.
3. Patients with vascular malformations discovered on brain imaging, without history of haemorrhage, are recommended for referral to relevant consultants including a neurosurgeon. In these cases.
4. Preventative surgery

Question 8

Secondary prevention?

Answer 8

1. Lower BP

2. Wait 4 wks before recommencing anticoagulant

Question 9

Haemorrhagic stroke - Differential diagnosis?

Answer 9

For Ischaemic Stroke:

1. Symptoms occur suddenly
2. Do not exhibit GI symptoms (N/V) or headache typically.

Question 10

Haemorrhagic stroke - Differential diagnosis?

Answer 10

For hypertensive Encephalopathy:

1. HTN significantly above patient’s baseline BP associated with headache.
2. Decreased consciousness or cognitive abnormalities, visual changes or loss, and signs of increased intracranial pressure.
3. Patients present with focal abnormalities in the neurological examination.