1. uOttawa.ca Hemorrhagic Stroke Dr. Grant Stotts, Director Ottawa Stroke Program 09 FEB 2016 uOttawa.ca Faculté de médecine | Faculty of Medicine

2. uOttawa.ca Hemorrhagic Stroke 2 major types –Subarachnoid Hemorrhage (SAH) –Intracerebral Hemorrhage (ICH) 2

3. uOttawa.ca Hemorrhagic Stroke Objectives ① 4830 Discuss the epidemiology and etiology of cerebral aneurysms. ② 4831 List the common anatomic sites of aneurysmal formation. ③ 4832 Describe the common clinical manifestations of a) a sentinel bleed and b) an aneurysmal rupture and c) compression from giant unruptured aneurysms. ④ 4833 Describe the investigation and management principles of patients with suspected subarachnoid hemorrhage (SAH). ⑤ 4834 Discuss potential complications of SAH, including vasospasm and hydrocephalus. ⑥ 4835 Discuss how hemorrhagic stroke differs from ischemic stroke in its clinical and radiologic presentation. ⑦ 4836 List the most common causes and manifestations of subarachnoid and intracerebral hemorrhage. ① 4830 Discuss the epidemiology and etiology of cerebral aneurysms. ② 4831 List the common anatomic sites of aneurysmal formation. ③ 4832 Describe the common clinical manifestations of a) a sentinel bleed and b) an aneurysmal rupture and c) compression from giant unruptured aneurysms. ④ 4833 Describe the investigation and management principles of patients with suspected subarachnoid hemorrhage (SAH). ⑤ 4834 Discuss potential complications of SAH, including vasospasm and hydrocephalus. ⑥ 4835 Discuss how hemorrhagic stroke differs from ischemic stroke in its clinical and radiologic presentation. ⑦ 4836 List the most common causes and manifestations of subarachnoid and intracerebral hemorrhage.

4. uOttawa.ca DISCUSS HOW HEMORRHAGIC STROKE DIFFERS FROM ISCHEMIC STROKE IN ITS CLINICAL AND RADIOLOGICAL PRESENTATION Objective 4835

5. uOttawa.ca Intracerebral Hemorrhage (ICH)

6. uOttawa.ca Presentation of ICH  Acute onset neurological deficit  Deficit depends on location of bleed – same as ischemic stroke  Contralateral hemiparesis/sensory loss and visual field deficits are common with hemispheric ICH  Ataxia can develop with cerebellar hemorrhage  Brainstem deficits can occur with ICH in the brainstem or if it creates pressure on the brainstem  Often:  Headache  Vomiting  Progressive deterioration in level of consciousness and/or worsening deficits

7. uOttawa.ca Clinical Differentiation of Ischemic and Hemorrhagic Stroke  Clinically, a stroke is more likely hemorrhagic if:  Rapid deterioration in level of consciousness  Headache +/- Vomiting  History of trauma  However:  Imaging is necessary to verify  Usually CT scan

8. uOttawa.ca Radiological Differentiation of Ischemic and Hemorrhagic Stroke Computed tomography (CT) is the most widely used imaging modality to determine acute stroke type Hemorrhagic Stroke –Blood (acutely) is more dense than brain tissue Will appear bright on CT immediately Ischemic stroke –Initially CT Head may be normal –With tissue death there is (cytotoxic) edema involving cellular swelling –This leads to a decrease in tissue density –May take hours to develop

9. uOttawa.ca Management of ICH Limit progression of hematoma –Reverse anticoagulation if taking warfarin or newer anticoagulant agents –Control blood pressure Investigate for underlying cause of hemorrhage –Vascular malformations CT or MR Angiogram often done initially –Other causes can be investigated if this testing is negative 3 Hours Later Initial CT Courtesy: Dr. D. Dowlatshahi

10. uOttawa.ca CT Angiogram Demonstrates Vasculature CT HeadCT Angiogram

11. uOttawa.ca Arteriovenous Malformation Abnormal network of vessels between arteries and veins without intervening capillaries. CT AngiogramCatheter Angiogram

12. uOttawa.ca LIST THE MOST COMMON CAUSES AND MANIFESTATIONS OF SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE Objective 4836

13. uOttawa.ca Causes of Intracerebral Hemorrhage: Location is Associated with Etiology 1.Subcortical Hypertension most common cause 2.Lobar Involving major lobes of the brain Hemorrhage extends out to the cortex Examples: Amyloid angiopathy Anticoagulant-associated hemorrhage Coagulopathy-associated hemorrhage Subcortical Lobar

14. uOttawa.ca Subcortical Hemorrhage Etiology Hypertension leads to formation of microaneurysms in small, penetrating arteries –Lenticulostriate vessels, branches usually from middle cerebral artery, degenerate with prolonged hypertension –Note these same vessels are responsible for lacunar ischemic infarcts as the vessels can also develop hypertrophy with prolonged hypertension –These vessels are too small to be seen on any available imaging. The CIBA Collection of Medical Illustrations volume I, Nervous System Part II, Neurologic and Neuromuscular Disorders. Frank H. Netter. Pg. 59

15. uOttawa.ca Lobar Hemorrhage Etiologies Major Etiologies: –Bleed into tumor –Bleed after ischemic infarct –Anticoagulant medications –Coagulopathy –Amyloid angiopathy

16. uOttawa.ca Amyloid Angiopathy: Connection to Alzheimer’s Disease (not on objective list) Amyloid Precursor Protein is cleaved into 2 predominant fragments –Soluble fragment (Aβ40) deposits in muscular layers of cerebral arteries and capillaries Vessels become fragile and spontaneously rupture Major cause of bleeding in the elderly –Insoluble fragment (Aβ42) deposits lead to amyloid plaque which is one of the major pathological findings in Alzheimer’s Disease These conditions can overlap but may also occur independently Stroke 2009;40;2601-2606

17. uOttawa.ca DISCUSS THE EPIDEMIOLOGY AND ETIOLOGY OF CEREBRAL ANEURYSMS Objective 4830

18. uOttawa.ca Cerebral Aneurysms: Background Intracranial aneurysms occur in 1 to 5% of the population –Autopsy studies –50 – 80% do not rupture More common in: –Adults –Women Associated factors: –Hypertension –Smoking –Excessive EtOH use Familial forms are less common (10%) Strong association with polycystic kidney disease

19. uOttawa.ca Two Major Factors of Cerebral Aneursym Formation Location at artery bifurcation Defect in arterial wall: tunica media

20. uOttawa.ca Factors Influencing Cerebral Aneurysm Rupture Risk More likely to rupture if –Larger (> 7 mm) –Growth with time Other factors –HTN –Smoking

21. uOttawa.ca Causes of Subarachnoid Hemorrhage Majority due to trauma Spontaneous SAH –Aneurysm 85% Clinically one of the most important presentations to recognize Mortality rate: 30-40% Most survivors are disabled –Other: cocaine, vasculitis, coagulopathy

22. uOttawa.ca LIST THE COMMON ANATOMIC SITES OF ANEURYSMAL FORMATION Objective 4831

23. uOttawa.ca Cerebral Aneurysm Locations Cerebral aneurysms tend to occur at arterial bifurcations NEJM 2006;355:928-39.

24. uOttawa.ca Cerebral Aneurysms Occur at Arterial Bifurcations

25. uOttawa.ca Major Cerebral Arteries Travel in the Subarachnoid Space Cerebral arteries follow subarachnoid space –The subarachnoid space is continuous through the brain and spine. –Therefore, a lumbar puncture can test for blood products even if the hemorrhage was intracranial.

26. uOttawa.ca DESCRIBE THE COMMON CLINICAL MANIFESTATIONS OF: - ANEURYSMAL RUPTURE - A SENTINEL BLEED - COMPRESSION FROM GIANT UNRUPTURED AN ANEURYSMS Objective 4832

27. uOttawa.ca Compression from Giant Aneurysms What is the deficit? Which CN nerve raises the eyelid? Which CN lowers the eyelid?

28. uOttawa.ca Compression from Giant Aneurysms Cranial nerve deficits –CN III palsy from Posterior Communicating Artery aneurysm most common Headache Seizure

29. uOttawa.ca Clinical Manifestations of SAH Thunderclap Headache –Maximal at onset Predominant clinical feature –Severe in intensity (10 out of 10)

30. uOttawa.ca Aneurysmal Rupture Clinical Presentation –Acute, thunderclap, headache –Acute loss of consciousness –Nausea, vomiting –Seizure –Clinical deficits may occur if pressure is high enough to injure surrounding tissue

31. uOttawa.ca Sentinel Bleed Sentinal = Minor bleed –Likely represents minor hemorrhage with rapid thrombus formation within the aneurysm Occurs in ~ 20% of SAH cases –80% will not have clinical warning Rebleed rate: 50% in 1 week Clinical recognition allows for time window to detect aneurysms –Symptoms similar to SAH with thunderclap headache

32. uOttawa.ca DESCRIBE THE INVESTIGATION AND MANAGEMENT PRINCIPLES OF PATIENTS WITH SUSPECTED SUBARACHNOID HEMORRHAGE (SAH) Objective 4833

33. uOttawa.ca Investigation of Thunderclap Headache for Possible SAH CT Head –95% sensitivity for detecting hemorrhage –Most sensitive if done < 12 hours

34. uOttawa.ca Investigation of Thunderclap Headache for Possible SAH If a CT Head is normal with a person presenting with thunderclap headache then a lumbar puncture is necessary.

35. uOttawa.ca Lumbar Puncture

36. uOttawa.ca What would you expect to see in the CSF if there was a SAH? A.High protein B.High glucose C.High red blood cell count D.High platelet count

37. uOttawa.ca Traumatic Tap The spinal needle may pierce a blood vessel before reaching the subarachnoid space. A test is needed to determine if the blood is from the CSF.

38. uOttawa.ca Testing for a Traumatic Tap: Compare First Tube with Later Tube RBC count is tested in the first and last CSF tube collected –SAH, the RBC count will be similar between the 2 tubes –Traumatic LP: cell count will drop by the last tube if it is diluted by normal CSF SAH: First Tube RBC = Last Tube RBC Traumatic Tap: First Tube RBC > Last Tube RBC

39. uOttawa.ca If CT Normal and CSF Negative for RBCs: Test for Xanthochromia You should wait approximately 2 hours after headache onset before the LP is performed –Xanthochromia is a yellowish discoloration due to bilirubin from hemoglobin breakdown –Takes at least 2 hours to develop –Helpful if RBC count is low in the case of a sentinel bleed where there is no active bleeding Xanthochromia

40. uOttawa.ca Imaging of Cerebral Aneuryms When a SAH is detected by any of the previous tests, the next step is to determine if there is an underlying cerebral aneurysm. Non-invasive imaging: used first –CT Angiogram –MR Angiogram Invasive imaging may be necessary –Catheter cerebral angiogram

41. uOttawa.ca Cerebral Aneurysm Management Surgical Clipping Historically the most common way to treat cerebral aneurysms Endovascular Coiling Generally considered first-line treatment for the majority of aneurysms presently NEJM 2006;355:928-39.

42. uOttawa.ca Cerebral Aneurysm Coiling Catheter usually inserted into the femoral artery Angiograms can be performed to see position of catheter during the procedure Detachable coils are inserted into the aneurysm until it is filled Coils are thrombogenic Patients are followed by MR scanning to evaluate possibility of regrowth Avoids craniotomy NEJM 2006;355:928-39.

43. uOttawa.ca Cerebral Aneurysm Coiling Courtesy: Dr. C. Lum, Interventional Neuroradiology, Ottawa Hospital

44. uOttawa.ca DISCUSS POTENTIAL COMPLICATIONS OF SAH, INCLUDING VASOSPASM AND HYDROCEPHALUS Objective 4834

45. uOttawa.ca Complications of SAH Immediate –Decreased Level of Consciousness –Airway Protection –Cardiac Effects Arrhythmia –Seizure Delayed 1.Rebleeding 2.Hydrocephalus 3.Vasospasm

46. uOttawa.ca Immediate Management of SAH ABCs ECG to look for cardiac arrhythmia Admit to hospital even if small SAH and patient looks currently stable in order to monitor for the possibility of delayed complications.

47. uOttawa.ca Management of Delayed Complications of SAH 1.Rebleeding –Secure aneurysm by endovascular coiling or surgical clipping

48. uOttawa.ca Management of Delayed Complications of SAH 2.Hydrocephalus –Blood obstructs CSF outflow pathways (arachnoid villi) –CSF accumulates and expands, increasing intracranial pressure –Surgically drain CSF if required

49. uOttawa.ca Management of Delayed Complications of SAH 3.Vasospasm –Uncertain cause, components of blood breakdown suspected –Severe vasospasm can lead to ischemia (stroke) –Usually 3 - 7 days after onset of SAH –Treated with BP elevation and vasodilators

50. uOttawa.ca Conclusions SAH Diagnosis –Thunderclap headache –CT –Lumbar Puncture when necessary Management –Stabilize and observe –Secure aneurysm –Watch for delayed hydrocephalus or vasospasm ICH Location correlates with etiology –Subcortical: Hypertension –Cortical: Amyloid angiopathy Management: –Control blood pressure –Investigate for underlying vascular cause