Hemorrhagic Stroke Pdf
Maricel Fergason
Hemorrhagic strokes make up about 13% of stroke cases. They occur when a weakened vessel ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.
Normally, arteries carry blood containing oxygen from the heart to the brain, and veins carry blood with less oxygen away from the brain and back to the heart. When an arteriovenous malformation (AVM) occurs, a tangle of blood vessels in the brain bypasses normal brain tissue and directly diverts blood from the arteries to the veins.
Symptoms may vary depending on where the AVM is located. This could include a wide variety of brain functions, such as difficulties with movement, coordination, sensation, thinking or memory, speech or vision. Severity can vary greatly.
Each time blood leaks into the brain, normal brain tissue is damaged. This results in loss of normal function, which may be temporary or permanent. The chance of permanent brain damage is 20% to 30%. The risk of death related to each bleed is 10% to 15%.
Most AVMs are detected with a computed tomography (CT) brain scan or magnetic resonance imaging (MRI) brain scan. For any type of treatment involving an AVM, an angiogram may be needed to better identify the type of AVM.
The best treatment is usually endovascular surgical blocking of the abnormal connections that have caused the fistula. This involves inserting small tubes (catheters) inside the blood vessel with X-ray guidance and blocking off the abnormal connections.
Surgery: If an AVM has bled and/or is in an area that can be easily accessed, then surgery may be recommended. Microsurgery allows the surgeon to work on small structures in the brain using a microscope and small, precise instruments.
Interventional neuroradiology/endovascular embolization: It may be possible to treat part or all AVM by placing a catheter inside the blood vessels and blocking off the abnormal vessels with various materials such as glue or coils.
Aneurysms usually develop at branching points of arteries and are caused by constant pressure from blood flow. They often enlarge slowly and become weaker as they grow, just as a balloon becomes weaker as it stretches. Aneurysms may be associated with other types of blood vessel disorders, such as fibromuscular dysplasia, cerebral arteritis or arterial dissection, but these are very unusual. Some aneurysms are due to infections, drugs such as amphetamines and cocaine or direct brain trauma from an accident. About 30,000 ruptured cerebral aneurysms occur each year in the U.S. Up to 6% of the population may have an unruptured cerebral aneurysm.
Smaller aneurysms may not have symptoms. As an aneurysm enlarges, it can produce headaches or localized pain. If an aneurysm gets very large, it may produce pressure on the normal brain tissue or adjacent nerves. This pressure can cause difficulty with vision, numbness or weakness of an arm or leg, difficulty with memory or speech, seizures, nausea, vomiting or loss of consciousness.
Many factors determine whether an aneurysm is likely to bleed. These include the size, shape and location of the aneurysm and symptoms that it causes. Smaller aneurysms that are uniform in size may be less likely to bleed than larger, irregularly shaped ones.
*Blood thinners (such as warfarin), some medications and prescription drugs (including diet pills that act as stimulants such as ephedrine and amphetamines), and harmful drugs such as cocaine can cause aneurysms to rupture and bleed.
(*Some medications are commonly called blood thinners because they can help reduce a blood clot from forming. Common blood thinners are anticoagulants such as warfarin or heparin that slow down the clotting process and antiplatelet drugs such as aspirin and clopidogrel that prevent platelet blood cells from clumping together to build a clot.)
After blood enters the brain and the space around it, direct damage to the brain tissue and brain function results. The amount of damage is usually related to the amount of blood. Damage is due to the increased pressure and swelling from bleeding directly into the brain tissue, or from local cellular damage to brain tissue from irritation of blood in the space between the brain and the skull.
Blood can also irritate and damage the normal blood vessels and cause vasospasm (constriction). This can interrupt normal blood flow to the healthy brain tissue and can cause even more brain damage. This is called an ischemic stroke.
Special imaging tests can detect a brain aneurysm. In the CTA (computed tomographic angiography), patients are placed on a table that slides into a CT scanner. A special contrast material (dye) is injected into a vein, and images are taken of the blood vessels to look for abnormalities such as an aneurysm. In the second test, called MRA (magnetic resonance angiography), patients are placed on a table that slides into a magnetic resonance scanner, and the blood vessels are imaged to detect a cerebral aneurysm.
Cerebral angiogram is most reliable in identifying the exact location, size and shape of aneurysms, and can be useful to fully map a plan for therapy. In this test, the patient lies on an X-ray table. A small tube (catheter) is inserted through a blood vessel, usually in the leg (groin), and guided into each of the blood vessels in the neck that go to the brain. Contrast is then injected, and pictures are taken of all the blood vessels in the brain. This test is slightly more invasive and less comfortable.
Hemorrhagic stroke is due to bleeding into the brain by the rupture of a blood vessel. Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Hemorrhagic stroke is associated with severe morbidity and high mortality. Progression of hemorrhagic stroke is associated with worse outcomes. Early diagnosis and treatment are essential given the usual rapid expansion of hemorrhage, causing sudden deterioration of consciousness and neurological dysfunction. This activity highlights the role of the interprofessional team in the evaluation and treatment of hemorrhagic stroke.
Objectives:
- Summarize the pathophysiology of hemorrhagic stroke.Identify the most common causes of hemorrhagic stroke and the most common site of the bleeding.Review the common presentations of this hemorrhagic stroke.CT scan is the initial investigation of choice. Prompt medical, sometimes surgical (in indicated cases), management is needed for recovery from hemorrhagic stroke.
Cerebrovascular accident (CVA), otherwise called a stroke, is the third major cause of morbidity and mortality in many developed countries. Stroke can be either ischemic or hemorrhagic. Ischemic stroke is due to the loss of blood supply to an area of the brain. It is a common type of stroke.
Hemorrhagic stroke is due to bleeding into the brain by the rupture of a blood vessel. Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH is bleeding into the brain parenchyma, and SAH is bleeding into the subarachnoid space. Hemorrhagic stroke is associated with severe morbidity and high mortality.[1] Progression of hemorrhagic stroke is associated with worse outcomes. Early diagnosis and treatment are essential given the usual rapid expansion of hemorrhage, causing sudden deterioration of consciousness and neurological dysfunction.
The usual causes of spontaneous subarachnoid hemorrhage (SAH) are ruptured aneurysm, arteriovenous malformation, vasculitis, cerebral artery dissection, dural sinus thrombosis, and pituitary apoplexy. The risk factors are hypertension, oral contraceptive pills, substance abuse, and pregnancy.
Hemorrhagic stroke contributes to 10% to 20% of strokes annually.[4][1][5] The percentage of hemorrhage in stroke is 8-15% in the United States of America, the United Kingdom, and Australia, and 18% to 24% in Japan and Korea. The incidence is around 12% to 15% of cases per 1,00,000 per year. The incidence is high in low and middle-income countries and Asians. The incidence is more common in men and increases with age. The global incidence is increasing, predominantly in African and Asian countries. Japanese data have shown that control of hypertension reduces the incidence of ICH. The case fatality rate is 25% to 30% in high-income countries, while it is 30% to 48% in low- to middle-income countries. The ICH fatality rate depends on the efficacy of critical care.
Secondary injury is contributed to by inflammation, disruption of the blood-brain barrier (BBB), edema, overproduction of free radicals such as reactive oxygen species (ROS), glutamate-induced excitotoxicity, and release of hemoglobin and iron from the clot.
Usually, the hematoma enlarges in 3 hours to 12 hours. The enlargement of hematoma occurs in 3 hours in one-third of cases. The perihematomal edema increases within 24 hours, peaks around 5 to 6 days, and lasts up to 14 days. There is an area of hypoperfusion around the hematoma. The factors causing deterioration in ICH are an expansion of hematoma, intraventricular hemorrhage, perihematomal edema, and inflammation.[1] Cerebellar hematoma produces hydrocephalus by compression of the fourth ventricle in the early stage.
Non-aneurysmal spontaneous subarachnoid hemorrhage may be either perimesencephalic or non-perimesencephalic SAH. In perimesencephalic SAH, bleeding is mainly in the interpeduncular cistern. Physical exertion, such as the Valsalva maneuver producing increased intrathoracic pressure, and elevated intracranial venous pressure, is a predisposing factor for perimesencephalic nonaneurysmal SAH (PM-SAH).[8] There is diffuse blood distribution in non-perimesencephalic SAH (NPM-SAH).[9]
The common presentations of stroke are headache, aphasia, hemiparesis, and facial palsy.[10] The presentation of hemorrhagic stroke is usually acute and progressing. Acute onset headache, vomiting, neck stiffness, increases in blood pressure, and the rapidly developing neurological signs are the common clinical manifestations of hemorrhagic stroke.[5] Symptoms can lead to the extent and location of hemorrhage.
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