Stroke (Haemorrhage)

Question 1

Causes of intracerebral hemorrhage

Answer 1

Hypertension, blood diseases

Question 2

Pathophysiology of hemmorhagic stroke

Answer 2

The expanding blood clot dissects and destroys brain tissue

 It acts like space-occupying lesion causing high intracranial pressure

 High ICP may affect cerebral perfusion

 High ICP in one compartment may displace structures and cause herniation

 Brain stem compression cause death

Question 3

Clinical feature of hemorrhagic stroke

Answer 3

Stroke usually occurs while the patient is awake or exerting

 Sudden onset within minutes

 Often associated with severe headache and vomiting. Seizures
are common

Clinical features depend on:
 Site of bleeding
 Size of extravasation

Question 4

Small Rupture may result in?

Answer 4

May result in leak of blood into subarachnoid space (SubArachnoid Hemorrhage - SAH) - headache

Question 5

Major Rupture may result in?

Answer 5

Results in loss of consciousness, could be preceded by severe
headache and severe exertion.

 Usually without focal deficits

Question 6

Complications of major rupture

Answer 6

Vasospasm: Presence of blood may irritate one or more arteries
causing vasospasm and ischemia within 1 or 2 weeks

 Hydrocephalus: Blockage of reabsorption of CSF can result in
hydrocephalus and increase in ICP

 Rerupture: chances are higher

Question 7

Ganglionic hemorrhage

Answer 7

Contralateral hemiplegia which worsens to drowsiness and
coma

Question 8

Thalamic hemorrhage

Answer 8

Contralateral hemiplegia with involvement of third nerve

Question 9

Pontine hemorrhage

Answer 9

Quadriplegia, pin-point pupils, death

Question 10

Cerebellar hemorrhage

Answer 10

Ataxia, altered sensorium, death

Question 11

Subarchnoid hemorhhage

Answer 11

Commonly due to saccular aneurysms of cerebral arteries

Question 12

Saccular aneurysms (Berry aneurysm)

Answer 12

Congenital pouch-like dilatations of the arterial wall.

Rupture of the dome occurs in adolescents

Question 13

Clinical features of SAH

Answer 13

Sudden onset of worst
headache ever
experienced

Vomiting

May or may not loose
consciousness

Commonly no focal
neurological deficits

Question 14

Medical management

Answer 14

Stop antiplatelet & anticoagulation

 Reverse the antithrombotic effect and correct coagulation

 ICH: Maintain SBP <160 mmHg or >120 mmHg

 SAH: Maintain MAP <130 mmHg or >80 mmHg

 Monitor neurological condition

 Control ICP (CPP = MAP – ICP)

 Keep BSL 6-10mmol/L

 Consider surgical interventions

Question 15

Surgical and interventional management

Answer 15

Surgical management of complication of SAH

External ventricle drainage (EVD) for

 hydrocephalus

 reduce intracranial pressure due to brain swelling

 Intracranial pressure monitoring

Secondary prevention of re-bleeding

• Clipping of aneurysm
• Coiling of aneurysm

Question 16

Post surgery management

Answer 16

Reduce risk of re-bleeding
 Maintain SBP 120-140mmHg

Prevent vasospasm ( post- operation)
 Nimodipine

Prevent seizure
 Phenytoin or Valproate

 Control ICP/BSL/fever