1. Hemorrrhagic Stroke

2. 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)

3. 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

4. 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

5. 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

6. 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

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

8. 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

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

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

11. 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

12. Complications Rebleeding Cerebral vasospasm Cerebral ischaemia
Acute hydrocphalus
seizures

13. 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

14. 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

15. 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.

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

17. 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

18. 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

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

27. Right middle cerebral artery aneurysm

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

30. 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.

31. 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)

33. Vertebral Angiogram shows aneurysm of the top of the Basilar Artery