Stroke and Intracerebral Hemorrhage

Question 1

Important differences in stroke and intracerebral hemorrhage presentation

Answer 1

• Both have sudden-onset focal deficits
• Hemorrhage more likely to be associated with headache, nausea/vomiting, and depressed level of consciousness – all due to elevated intracranial pressure and mass effect
• These are not hard-and-fast, as large ischemic strokes can still present with the above

Question 2

As soon as a stroke or intracerebral hemorrhage is on the differential, a ___ must be performed.

Answer 2

As soon as a stroke or intracerebral hemorrhage is on the differential, a diagnostic CT scan must be performed.

Question 3

Most important considerations for stroke and intracerebral hemorrhage

Answer 3

• Pressure
• Coagulation status

In acute ischemic stroke, the goal is to prevent thrombosis and promote fibrinolysis while maintaining blood pressure. In intracerebral hemorrhage, the goal is to stop bleeding and reduce blood pressure.

Question 4

Acute supportive care that is used for both ischemic stroke and intracerebral hemorrhage

Answer 4

• ECG and cardiac monitoring (may cause stroke or be caused by stroke)
• Evaluation of swallowing and prevention of aspiration
• Control of blood glucose to avoid hypoglycemia or hyperglycemia.
• Maintenance of euthermia (by treating fever and underlying infection if it occurs)
• Treatment of seizures if they occur
• Evaluation for and management of elevated intracranial pressure
• Early mobilization
• Deep venous thrombosis (DVT) prophylaxis
• Physical therapy, speech therapy, and/or occupational therapy.​

Question 5

When to start DVT prophylaxis in patients with cerebrovascular accidents

Answer 5

• Started immediately after ischemic stroke unless tissue plasminogen activator (tPA) is administered (in which case it is delayed 24 hours)
• Generally not started until 24-48 hours after intracerebral hemorrhage.
• Mechanical prophylaxis can begin immediately after either type of stroke.

Question 6

Transient Ischemic Attack

Answer 6

• Transient stroke symptoms that resolve completely without evidence of infarction on MRI
• Most TIAs last for minutes to about an hour, and those that last longer often have evidence of infarction on DWI even if symptoms resolve completely
• ABCD2 score used to estimate risk

Question 7

Ischemic stroke etiologies and how to evaluate them

Answer 7

Question 8

Artery-to-artery embolism

Answer 8

Embolism from the carotid arteries or vertebral arteries to a more distal cerebral vessel

Question 9

Paradoxical embolism

Answer 9

If a patient has a patent foramen ovale, embolism from the venous circulation can cause stroke

Question 10

Non-thromboembolic emboli which may cause ischemic stroke

Answer 10

• Air embolism
• Fat embolism
• Amniotic fluid embolism

Question 11

Lipohyalinosis of small penetrating arteries as a cause of ischemic stroke

Answer 11

Chronic hypertension can lead to thickening of the walls of the small penetrating arteries (small vessel disease), which can predispose to lacunar infarcts in the deep subcortical regions (internal capsule or thalamus) or the anterior pons

Question 12

Cervical artery dissection as a cause of ischemic stroke

Answer 12

• A tear between the layers of the wall of the cervical vessels (carotids and vertebral arteries)
• A common cause of stroke in the young and can be caused by head or neck trauma, including chiropractic manipulation
• May also be caused by collagen disorders such as Ehlers-Danlos syndrome
• The risk of stroke is highest in the first week after dissection, and some patients may have multiple TIAs or strokes during this period.

Question 13

Vasospasm as a cause of ischemic stroke

Answer 13

• Vasospasm can be caused by:
  
  • Local irritation of the blood vessels by subarachnoid hemorrhage or meningitis
  • Failure of cerebral autoregulation, which can be seen in posterior reversible encephalopathy syndrome (PRES)
  • Drugs such as cocaine and marijuana, and medications such as selective serotonin reuptake inhibitors (SSRIs) and sympathomimetic-containing cold medications can cause reversible cerebral vasoconstriction syndrome

Question 14

Vasculopathy and vasculitis as a cause of ischemic stroke

Answer 14

• Radiation-induced vasculopathy
• Reversible cerebral vasoconstriction syndrome (RCVS), which can cause stroke or hemorrhage
• Moyamoya syndrome
• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL)
• Vasculitis: blood vessel inflammation that may be primary or secondary

Question 15

Cardiac Causes of Ischemic Stroke

Answer 15

• Atrial fibrillation
• Valvular disease
• Left HFrEF
• Myocardial infarction
• Infective endocarditis with septic embolization
• Nonbacterial thrombotic endocarditis
• Cardiac tumors on which thrombus may form
• Patent foramen ovale and paradoxical embolism
• Cardiac arrest with hypoxic-ischemic injury

Question 16

Hematologic Causes of Acute Ischemic Stroke

Answer 16

• Hypercoagulable states
• Sickle cell
• Hyperviscosity, which can be caused by polycythemia vera and Waldenström’s macroglobulinemia
• Intravascular lymphoma

Question 17

Initial evaluation of patient with suspected stroke

Answer 17

• Monitoring all vitals, ECG, blood sugar, basic chemistries, complete blood count, and coagulation while patient is under clinical evaluation
• In practice, when acute stroke is suspected, history and examination are often performed en route to a CT scan since the use of thrombolytic treatment for acute ischemic stroke requires rapid confirmation of the diagnosis
• Evaluation for coagulopathy should also be obtained prior to initiating thrombolytic therapy (platelets, PT, PTT, INR)
• If CTA is to be performed, serum creatinine should also be measured to determine whether it is safe to administer intravenous contrast.

Question 18

Neuroimaging of acute stroke

Answer 18

• The CT scan may show no abnormalities in the acute setting of acute ischemic stroke since the CT hypodensity caused by ischemic stroke can take up to 12 hours to emerge.
• If the clinical impression is that the patient is having an ischemic stroke, the CT scan does not reveal an alternative explanation for the patient’s symptoms, and the time of onset of symptoms is well established with the patient having presented within the 3-hour window, the patient can be considered for thrombolytic therapy if there are not contraindications

Question 19

Ischemic strokes do not become visible on fluid-attenuated inversion inversion recovery (FLAIR) imaging until about ___ from onset

Answer 19

Ischemic strokes do not become visible on fluid-attenuated inversion inversion recovery (FLAIR) imaging until about 6 hours from onset

Question 20

Subacute strokes (about 1 week to 1 month old) can demonstrate . . .

Answer 20

Subacute strokes (about 1 week to 1 month old) can demonstrate enhancement on postcontrast CT or MRI

Question 21

Evaluation for etiology of ischemic stroke

Answer 21

• Screen for modifiable risk factors: blood pressure, diabetes (serum glucose or hemoglobin A1c), hyperlipidemia (by serum lipids), smoking, and/or excessive alcohol use.
• The intracranial and cervical vasculature can be assessed by MRA, CTA, or digital subtraction angiography. If these are contraindicated, Doppler ultrasound may be used
• Evaluate heart for thrombosis, dilation, endocarditis, valvular disease, and afib or other arrhythmia. Echocardiography, EKG. If nothing apparent, set up prolonged heart monitoring with ambulatory EKG leads.

Question 22

Cryptogenic stroke

Answer 22

The etiology of most strokes is discovered on basic metabolic, vascular, and cardiac screening.

However, this is not always the case. Cryptogenic strokes are strokes that have no discernable cause in the above categories, and they require additional testing.

Question 23

Evaluation of a cryptogenic stroke

Answer 23

• Prolonged cardiac monitoring for paroxysmal arrhythmia
• Agitated saline (bubble) study during the echocardiogram to look for patent foramen ovale (PFO). If found, venous vasculature should be surveyed for thrombosis.
• Evaluation for a hypercoagulable state – PT, PTT, INR, clotting factors, anti-phospholipid antibodies
  
  • Screen for malignancy by positron emission tomography (PET) scan or CT (may also cause hypercoagulable state)
• Lumbar puncture to look for signs of an inflammatory or infectious etiology if vasculopathy is suggested on vascular imaging
• Transesophageal echocardiogram (as opposed to transthoracic, which is typically done in initial screening)
• Blood cultures if there is concern for infectious endocarditis

Question 24

May-Thurner syndrome

Answer 24

• Compression of the left common iliac vein by the right common iliac artery leads to hemostasis and thrombosis
• This may then be a cause of subsequent embolism into the IVC
• May cause pulmonary embolism, OR, in patients with a PFO, may cause a paradoxical embolic ischemic stroke

Question 25

Prevalence of PFO

Answer 25

25% in general population

40% in cryptogenic stroke population

According to a 2017 study.

Question 26

Primary vs Secondary stroke prevention

Answer 26

Primary stroke prevention refers to modification of risk factors to prevent a first stroke.

Secondary stroke prevention refers to modifying risk factors after stroke or TIA to reduce the risk of a subsequent stroke.

Question 27

Secondary stroke prevention measures

Answer 27

• Hyperlipidemia should be controlled by diet, exercise, and statin therapy.
• Hypertension should be controlled by diet, exercise, and if necessary, antihypertensive medications.
• Blood sugar in diabetics should be controlled by diet, exercise and if necessary, medications.
• Patients should be aided in quitting smoking and reducing excessive alcohol intake.
• Patients should be on an antiplatelet agent (unless they require anticoagulation)
• Patients with atrial fibrillation should be anticoagulated with warfarin or a novel oral anticoagulant unless contraindicated
• Patients with symptomatic moderate or severe carotid stenosis should be considered for intervention with carotid endarterectomy or carotid artery stenting
• Patients with hypercoagulable states may require anticoagulation.

Question 28

In comparison to ischemic stroke, intracerebral hemorrhage is more often accompanied by. . . .

Answer 28

• Headache
• Nausea/vomiting
• Depressed level of consciousness at onset (due to pressure and/or mass effect)
• Extreme hypertension (diastolic pressure >110 mm Hg)
• Seizures at presentation

Question 29

Apperance of ischemic stroke vs intracerebral hemorrhage on CT at presentation

Answer 29

On CT, acute blood is hyperdense and visible at presentation.

This is in contrast to acute ischemic stroke, in which CT scan may be normal at presentation

Question 30

Spot sign in intracerebral hemorrhage

Answer 30

Vascular imaging (e.g., CTA or MRA) should be performed when intracerebral hemorrhage is suspected to assess for a vascular malformation that may require surgical intervention.

If one or more spots of contrast is seen in the hematoma (spot sign), this is associated with a higher risk of hematoma expansion

Question 31

Acute management of intracerebral hemorhage

Answer 31

• Acute management of ICH is geared toward prevention of hematoma expansion by lowering the blood pressure and reversing any coagulopathy if present
  
  • Intravenous antihypertensive infusion (typically with nicardipine) guided by intra-arterial blood pressure monitoring is often necessary.
  • Lower to at least 180 mmHg systolic
• Patients must be monitored in an ICU with CT scan repeated for any change in neurologic examination.
• Electoencephalography (EEG) should be considered to evaluate for nonconvulsive seizures in patients whose examination appears to be worse than would be expected

Question 32

ICH expansion occurs most commonly in ____, and within that period, most commonly within ____

Answer 32

ICH expansion occurs most commonly in the first 24 hours, and within that period, most commonly within the first 6 hours

Question 33

If a patient who is warfarinized presents with acute intracerebral hemorrhage, one of the first steps should be to. . . .

Answer 33

. . . give IV vitamin K and fresh frozen plasma or prothrombin complex concentrate to reverse warfarinization

Question 34

If a patient who is heparinized presents with acute intracerebral hemorrhage, one of the first steps should be to. . . .

Answer 34

. . . give IV protamine sulfate.

Question 35

Repeat CT scans for patients with ICH

Answer 35

• Patients with acute ICH must be monitored closely in an intensive care unit setting with CT scan repeated for any change in neurologic examination.
• CT scans are typically repeated 6 hours after the initial scan and then at 24 hours to look for any evolution in the ICH

Question 36

Surgical evacuation of hematomas

Answer 36

In patients with large cerebellar ICH (>3 cm), surgical evacuation of the hematoma can be lifesaving.

Although supratentorial hematoma evacuation does not appear to improve overall outcomes, it may be considered in patients with ICH close to the cortical surface or ICH that expands with rapid clinical deterioration in patients with a reasonable chance of recovery.

Question 37

Etiologies of intracerebral hemorrhage

Answer 37

• Chronic hypertension – this form most often affects basal ganglia, anterior pons, and cerebellum
• Cerebral amyloid angiopathy
• Head trauma
• Coagulopathy or thrombocytopenia
• Rupture of a vascular malformation (aneurysm, AV malform, etc)
• Hemorrhage into an ischemic stroke (hemorrhagic conversion)
• Cerebral venous sinus thrombosis
• Cocaine (due to acute hypertension).
• Hemorrhagic cerebral metastases

Question 38

Hemorrhagic conversion

Answer 38

Hemorrhage into an ischemic stroke

More common with embolic strokes, septic emboli in endocarditis, and stroke in the PCA territory.

Question 39

When you see left-sided neglect, think of a lesion in the ___.

Answer 39

When you see left-sided neglect, think of a lesion in the right parietal lobe.

Question 40

If you see a ring on CT, it is likely. . .

Answer 40

. . . a central lesion with surrounding edema

Question 41

Fronto-temporal dementia

Answer 41

Type of dementia which presents with frontal lobe atrophy.

Presents with altered personality, disinhibition, abulia, and apperance of frontal release reflexes.

Question 42

Stroke syndrome summary

Answer 42

Question 43

A full motor stroke affecting one entire half of the body in the absence of other symptoms is probably localized to . . .

Answer 43

. . . the internal capsule or other midbrain territories. Probably a lacunar stroke.

Question 44

Wake-up strokes

Answer 44

Patient experiences a stroke as they are getting out of bed in the morning, or overnight as they were sleeping.

Question 45

Types of stroke that may alter consciousness

Answer 45

Strokes in the midbrain (particularly in the reticular activating system) or a large hemorrhage with diffuse compression of the brain.

Obstructive hydrocephalus from blood in the cerebrospinal fluid preventing CSF reabsorption commonly causes diffuse brain compression regardless of hemorrhage site, making hemorrhage slightly more likely for somnolent stroke patients.

Question 46

Deep-brain intracranial hemorrhages are often due to . . .

Answer 46

. . . hemorrhage of small blood vessels supplying the midbrain structures

Especially in patients with chronic hypertension and cigarette use/alcohol use.

Note that the risk factors for this are the same as the risk factors for a lacunar stroke, but they are clinically distinct phenomena.