Haemorrhagic stroke

Question 1

haemorrhagic stroke definition

Answer 1

haemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in

• intraparenchymal haemorrhage
• subarachnoid haemorrhage
• intraventricular haemorrhage

Question 2

aetiology of haemorrhagic stroke

Answer 2

1. Primary - spontaneous and absence of vascular malformation
2. Secondary - identifiable vascular malformation/complication of medical and neurological disease

Question 3

key diagnostic factors of haemorrhagic stroke

Answer 3

1. neck stiffness / photophobia / visual changes
2. history of liver disease
3. altered sensation / sensory loss
4. headache - insidious onset + gradually increasing intensity
5. unilateral muscle weakness
6. dysarthia
7. aphasia
8. ataxia

Question 4

most common symptoms of intracerebral haemorrhage

Answer 4

1. Limb weakness
2. Paraesthesias or numbness
3. Dizziness
4. Vertigo
5. Nausea/vomiting
6. Speech difficulty
7. Visual loss or double vision
8. Confusion
9. Headache.

Question 5

risk factors of haemorrhagic stroke

Answer 5

1. hypertension
2. advanced age
3. haemophilia
4. cerebral amyloid angiopathy
5. anticoagulation medication
6. Vascular malformations - AVF, cavernous malformations

Question 6

signs to differentiate ischaemic vs intracerebral haem

Answer 6

ICH is more commonly assoc with;

1. reduced levels of consciousness
2. increased intracranial pressure signs such as anausea and vomitting

Question 7

initial evaluation of ICH

Answer 7

1. Evaluate airway - breathing, pulse, circulation ( vascular access + BP checked )
2. Brief history of stroke symptoms + streamlined neuro exam
3. rapid physical assessment tool for stroke signs - NIH stroke score/ICH score

Question 8

Investigations to order (first line)

Answer 8

1. Non infused head CT - differentiates haemorrhagic from ischaemic stroke
2. chemistry panel - hypoglycaemia + electrolyte disturbances
3. FBC - exclude thrombocytopenia
4. Clotting tests / platelet function test
5. ECG - Myocardial ischaemia can complicate a stroke/
   - Large inverted t waves : suggest ECG changes of cerebral origin
6. LFTs
7. ICH score

Question 9

Second line investigations to consider

Answer 9

1. CT angiography/venography - rules out aneurysm/ AVM and venous thrombosis
   - recc in all pts < 45

Question 10

differentials

Answer 10

1. Ischaemic stroke
2. Hypoglycaemia
3. hypertensive encephalopathy
4. Complicated migraine
5. seizure disorder
6. conversion + somatisation disorder

Question 11

IS vs ICH

Answer 11

• Symptoms occur suddenly.
• In ischaemic stroke, patients do not exhibit gastrointestinal symptoms (N/V) or headache typically.
• Acute haemorrhage appears bright due to hyperattenuation of the x-ray beams in CT scan.

In contrast, ischaemic infarct appears as hypoattenuation (darkness), although may not appear for many hours after stroke onset.

Question 12

Hypertensive encephalopathy vs ICH

Answer 12

Hypertension significantly above patient’s baseline blood pressure associated with headache, decreased consciousness or cognitive abnormalities, visual changes or loss, and signs of increased intracranial pressure. Less frequently these patients present with focal abnormalities in the neurological examination.

Cerebral oedema on CT or MRI. Certain patients present characteristic changes in the posterior aspect of the brain.

Question 13

hypoglycaemia vs ICH

Answer 13

Sweating, tremor, hunger, confusion, and ultimately a decreased level of consciousness.

May have known history of diabetes mellitus and insulin use or medical conditions associated with hypoglycaemia.

Low serum glucose on blood chemistry.

Question 14

Manage`ment - OVERALL

Answer 14

1. Admission in ICU / Stoke unit for 24 hour surveillance
   - Airway protection to those with reduced consciousness/ endotracheal intubation for airway protection is recommeded
2. Supportive care
   - Supplemental oxygen if oxygen sat < 94%
   - Aspiration precaution
   - treat hyperglycaemia
   - Blood pressure control
   - DVT prophylaxis
   - Blood pressure control
   - Antipyretic measures
   - Correct coagulopathy
3. Potential Surgical intervention

Question 15

Surgical intervention

Answer 15

1. surgery in non cerebellar bleeds ( ie. in cerebrum + surrounding structures ) is controversial and no evidence to suggest it improves outcomes
2. Cerebellar haemorrhage can be lifesaving if
   - patient is drowsy/loss of consciousness
   - haemorrhage size >3cm

Question 16

Raised ICP management - ‘patients with intracranial haemorrhage are at risk of developing raised ICP from expanding haematoma/oedema/hydrocephalus/

Answer 16

1. head of bed elevation to 30 degrees
2. Mild hyperventilation - tracheal intubation and mechanical ventilation
3. Analgesia + sedation
4. External ventricular drainage of csf
5. osmotic therapy - mannitol / hypertonic saline
6. corticosteroids should not be used !! ( cause more compl )

Question 17

Aspiration precautions

Answer 17

1. swallowing impairment is common in stroke and associated with increased risk of aspiration pneumonia
2. nil by mouth + isotonic fluids via nasogastric tubes

Question 18

Seizure management

Answer 18

1. seizures affect 22% of stroke victims
2. prophylactic use of anticonvulsants have not been proven to be effective
3. anticonvulsants should be used to treat clinical seziures

Question 19

Management of anticoagulated patients

Answer 19

ALL PATIENTS WITH INTRACEREBRAL BLEED SHOULD BE GIVEN VITAMIN K INTRAVENOUSLY

1. correct hypocoaguble state - administration of anticoagulants should be ceased and antidotes administered

• Antidote for patients on warfarin INR > 1.5 :
  = phytomenadione ( Vitamin K) + Fresh frozen plasma/ 4 factor prothrombin concentrate
• Antidote for patients on heparin :
  = Protamine sulfate + platelet transfusion
• -

Question 20

Treatment of fever

Answer 20

• The presence of fever is common after intracerebral haemorrhage, especially when associated with intraventricular haemorrhage.
• The duration of fever has been associated with worse outcomes and has been established as an independent prognostic factor.
  1. Antipyretic - paracetamol recommended

Question 21

Treatment of hyperglycaemia

Answer 21

• Untreated hyperglycaemia is independently associated with poor prognosis in intracerebral haemorrhage;
• consequently, prompt glucose correction is recommended despite a lack of evidence for improving outcomes.

Question 22

DVT prophylaxis

Answer 22

1. Complications due to venous thromboembolism are very common in critically ill patients with neurological injury due to ;
   - increased venous stasis from paralysis
   - prolonged coma
2. The risk of venous thromboembolism may be higher in patients with haemorrhagic stroke as compared with patients with ischaemic stroke
3. Early mobilisation of patients is recommended
4. low-dose unfractionated or low molecular weight heparin may be considered >48 hours after onset as long as there is no evidence of continued bleeding

Question 23

Blood pressure control

Answer 23

• Elevated BP could promote further bleeding
• Requires treatment if systolic BP > 180

1. Labetalol - ( 5 - 20mg over 2 mins and 10-20mg every 10 minutes )
   or
2. Nicardipine - 5mg an hour intravenously

Question 24

complications of haemorrhagic stroke

Answer 24

1. DVT
2. Infections - aspiration pneumonia
3. Seizures
4. Hydrocephalus