Hemorrrhagic Stroke

Haemorrhagic Stroke Forms 15% of all cerebrovascular disorders Caused by an intracranial or subarachnoid haemorrhage – may be from ruptured aneurysm More severe deficits and prolonged recovery time compared to ischaemic stroke Hemorrhage into brain tissue, into the ventricles or the subarachnoid space. Rupture of a vessel is the cause for 80% of all bleeding Primarily caused by uncontrolled hypertension intracerebral haemorrhage - by arteriovenous malformation,aneurysms, certain medications (eg., anticoagulants and amphetamine)

Pathophysiology Aneurysm or AV malformation – presses on the nearby cranial nerves or brain tissue or more dramatically, when an aneurysm or AVM ruptures causing subarachnoid haemorrhage Normal brain metabolism is altered by direct exposure to blood, increased intracranial pressure Reduced perfusion vasospasm

Intracerebral hamorrhage Bleeding into the brain substance Common in hypertension and cerebral atherosclerosis – degenerative changes lead to rupture of the blood vessels Rupture may occur due to arterial pathology, brain tumour or due to drugs (oral anticoagulants, amphetamines and illicit drugs such as cocaine) Bleeding is usually arterial Most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem (mostly the pons) and cerebellum. Occasionally into the lateral ventricle

Intracranial (cerebral) aneurysm Weakness in the cerebral artery  aneurysm – usually at bifurcations of large arteries of the circle of Willis May be due to atherosclerosis, congenital defect in the vessel wall, hpertensive vascular disease, head trauma or aging Site : bifurcation of large arteries of the circle of Willis, internal carotid artery, posterior communicating artery, anterior communicating artery, posterior cerebral artery and middle cerebral artery Multiple cerebral aneurysms are not uncommon

Arteriovenous malformations An AVM is due an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed Absence of capillary bed leads to dilation of the arteries and veins and eventual rupture Common in the young

Subarachnoid Haemorrhage Into the subarachnoid space Avm, intra cranial aneurysm, trauma hypertension Most common : leaking aneurysm in the circle of Willis

Clinical Manifestations Disruption of motor, sensory, cognitive and cranial nerve functions Sudden and unusually severe headache LOC Nuchal rigidity Visual disturbances : visual loss, diplopia, ptosis (when adjacent to oculomotor nerve. Tinnitus dizziness and hemiparesis Cerebral damage  coma death

Assessment and diagnostic findings CT scan Cerebral angiography Toxicology screening to detect drug abuse in youngsters

Prevention Control hypertension Phenylpropanolamine (appetite suppression agents, cough medications and cold medications)

Medical Management Minimize the risk of rebleeding Bed rest Sedation to prevent agitation, and stress Management of vasospasm Surgical or medical treatment to prevent rebleed Analgesics to treat pain neck and rigidity Prevent DVT

Complications Rebleeding Cerebral vasospasm Cerebral ischaemia Acute hydrocphalus seizures

Cerebral hypoxia and decreased blood flow Supplemental O2 Correct Hb level Correct hematocrit Adequate hydration Bp to be maintained at an optimum level Seizure can compromise cerebral blood flow and hence to be avoided

Vasospasm Cerebral vasospasm is a serious complication of subarachnoid heamorrhage. Vasospasm  impedence to cerebral blood flow  morbidity and mortality ↑ . Signs and symptoms of vasospasm : worsening headache, a decrease in the level of consciousness (confusion, lethargy and disorientation) or a new focal neurologic deficit (aphasia, hemiparesis, 4 – 14 th day This is the time the clot undergoes lysis  rebleed Remedy : early clipping of the aneurysm, removing blood from the basal cisterns, nimodipine (calcium channel blocker) Endovascular techniques

Increased ICP Almost always follows a subarachnoid haemorrhage Deterioration in the condition due to : cerebral oedma, herniation, hydrocphalus, vasospasm). Mannitol, cautious lumbar puncture, ventricular catheter drainage. When mannitol is used guard against dehydration and its sequelae.

Systemic Hypertension Maintained at a moderate level : 150 systolic Seizures cause ↑ in BP – avoid Stool softeners – straining at stool ↑ BP

Surgical Management For many no surgical intervention In cerebellar hge strongly recommended > 3 cm and the Glasgow coma scale score < 14 Surgery : an aneurysm is clipped or ligatured at its neck, wrapped with muslin or any other suitable mesh Endovascular treatment (occlusion of the parent artery) and aneurysm coiling Postoperative complications : disorientation, amnesia Korsakoff’s syndrome

Nursing Interventions in a patient with haemorrhagic stroke Optimizing cerebral tissue perfusion Implementing aneurysm precautions – nonstimulating environment, prevent ↑ of ICP, prevent further bleeding, absolute bedrest, quiet room, no visitors, head end elevated, any activity that obstructs venous flow or that ↑s BP avoided eg. Valsalva maneuver, straining, forceful sneezing, pushing up in bed, acute flexion or rotation of head and neck. Cigarette stopped. No enemas; stool softeners permitted, dim light. No coffee nor tea

Prevent DVT Fed and bathed – no strain No television, no radio, no reading Explain the reason to the family and patient

Right middle cerebral artery aneurysm

Anterior-posterior (AP) and lateral views of a right internal carotid angiogram showing a posterior communicating artery aneurysm (arrow).

Anterior-posterior views of right internal carotid artery angiogram showing a right middle cerebral artery aneurysm (arrow) before (left panel) and after (right panel) microsurgical clipping.

CT head scan demonstrating large subarachnoid hemorrhage(SAH) CT head scan demonstrating large subarachnoid hemorrhage(SAH). Note small amount of blood in the bottom of the left lateral ventricle, IVH (bottom right of picture)

Vertebral Angiogram shows aneurysm of the top of the Basilar Artery