Tutorial paper and quizzes Flashcards
A past history of hypertension is particularly significant in precipitating a hemorrhagic stroke due to the following
reasons:
Vessel Weakening and Rupture: Chronic high blood pressure exerts constant pressure on the walls of blood vessels, causing them to weaken over time. This increases the risk of a vessel rupturing, leading to a hemorrhagic stroke.
Aneurysm Formation: Hypertension can lead to the formation of aneurysms, which are weakened, bulging areas in blood vessel walls. These aneurysms are prone to bursting, causing bleeding in the brain.
Microbleeds and Microangiopathy: High blood pressure can cause microbleeds and damage to the smaller blood vessels in the brain (microangiopathy), which increases the likelihood of hemorrhagic strokes.
Blood-Brain Barrier Breakdown: Chronic hypertension can disrupt the integrity of the blood-brain barrier, making it easier for blood to leak into the brain tissue if a vessel is damaged.
A thalamic bleed (Past history of Mr.Chua) can lead to changes in personality due to the following reasons: (4)
Impact on Emotional Regulation: The thalamus plays a key role in processing and relaying sensory information to the cerebral cortex, including areas involved in emotion and behavior. A bleed in this area can disrupt these pathways, leading to alterations in emotional regulation and personality traits.
Connection to the Limbic System: The thalamus is closely connected to the limbic system, which is responsible for controlling emotions, mood, and behavior. Damage to the thalamus can affect these connections, resulting in mood swings, irritability, or other changes in personality.
Cognitive and Executive Functioning: The thalamus is involved in cognitive functions such as attention, memory, and decision-making. A hemorrhage in the thalamus can impair these functions, leading to changes in how a person thinks, responds to situations, and interacts with others.
Effect on Frontal Lobe Connections: The thalamus has connections to the frontal lobes, which are crucial for higher-order functions like planning, judgment, and social behavior. Disruption of these connections can lead to disinhibition, impulsivity, and changes in social behavior, which are often perceived as changes in personality.
When a patient’s Glasgow Coma Scale (GCS) deteriorates to 8, pupils dilate, and SpO₂ drops to 85%, these symptoms can be concerning signs of increased intracranial
pressure (ICP) and possible brainstem involvement. However, these symptoms alone may not definitively pinpoint the exact location of the bleed, but they can give some clues:
Dilated pupils can suggest
Dilated pupils can suggest that the brainstem, particularly the midbrain, is being compressed or affected. The midbrain contains the oculomotor nerve (cranial nerve III),
which controls pupil constriction. A bleed that causes pressure on the midbrain could lead to pupillary dilation.
*If one pupil is dilated and unresponsive, this may indicate an ipsilateral (same side) brainstem compression or uncal herniation due to a temporal lobe bleed.
When a patient’s Glasgow Coma Scale (GCS) deteriorates to 8, pupils dilate, and SpO₂ drops to 85%, these symptoms can be concerning signs of increased intracranial
pressure (ICP) and possible brainstem involvement. However, these symptoms alone may not definitively pinpoint the exact location of the bleed, but they can give some clues:
A GCS score of 8 indicates
A GCS score of 8 indicates severe brain injury. This can be due to a large bleed or hemorrhage, potentially in areas that control consciousness, such as the thalamus or brainstem. A drop in GCS, particularly with such a low score, is often associated with significant brain damage or increased ICP
When a patient’s Glasgow Coma Scale (GCS) deteriorates to 8, pupils dilate, and SpO₂ drops to 85%, these symptoms can be concerning signs of increased intracranial
pressure (ICP) and possible brainstem involvement. However, these symptoms alone may not definitively pinpoint the exact location of the bleed, but they can give some clues:
A drop in SpO₂ to 85% could suggest
A drop in SpO₂ to 85% could suggest respiratory compromise. If the bleed affects the brainstem, specifically the medulla oblongata, which controls basic life functions
like breathing, it can lead to respiratory depression or arrest, causing oxygen saturation to fall
When a patient’s Glasgow Coma Scale (GCS) deteriorates to 8, pupils dilate, and SpO₂ drops to 85%, these symptoms can be concerning signs of increased intracranial
pressure (ICP) and possible brainstem involvement. However, these symptoms alone may not definitively pinpoint the exact location of the bleed, but they can give some clues:
Possible Locations of the Bleed:
*Brainstem: The combination of dilated pupils, GCS deterioration, and decreased SpO₂ strongly suggests possible brainstem involvement.
*Thalamus or Cerebellum: Bleeds in these regions can also cause severe symptoms and may contribute to increased ICP, leading to secondary brainstem compression.
*Hemispheric Bleed with Herniation: A large hemorrhage in the cerebral hemisphere could cause a shift in brain tissue (herniation), leading to brainstem compression.
MANIFESTATIONS OF BRAIN INJURY
Posturing
Decorticate posture (flexor)
Decerebrate posture (extensor)
Pathophysiology of HEMORRHAGIC STROKES
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
Mortality is high in hemorrhage
NEUROLOGICAL COMPLICATIONS of hemorrhage stroke (4)
Complications
Brainstem compression
Cerebellar herniation
Hydrocephalus
Recurrent haemorrhage within 24 hours
Non-neurological complications
10
HEMORRHAGIC STROKES
Complications of major rupture
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
CEREBELLAR HAEMORRHAGE (CH)
Medical management
- Stabilise the patient
Secure airway, intubate as needed using rapid sequence intubation
Persistent Hypertension - MAP of 130 mmHg or above – judicious use of labetalol or use another titratable antihypertensive
Cushing’s response: Bradycardia, HTN, apnoea; compensation for rising ICP
- In the case of Mr Chua, the Hypertension can be related to his hypertensive condition or related to Cushing’s response. When there is an increase in ICP, there is a subsequent increase in systolic BP that widens the pulse pressure causing bradycardia and then shallow breathing (periods of
apnoea).
In the early stages, of Cushing’s response, there can be tachycardia instead of bradycardia
Osmolar therapy using hypertonic agents – increase serum osmolality water movement
E.g., 3% saline
Decompression
Suboccipital craniotomy/craniectomy
How many general types of stroke are there?
2
Types of stroke that can be visualised immediately on CT scan
Haemorrhagic
Salvageable area around infarction
Penumbra
Which condition is associated with worst headache experienced by a patient
Hemorrhagic stroke
