In this blog we will be discussing Hemorrhagic stroke. It accounts only for 15% of the total cerebrovascular attacks but is responsible for 40% of stroke related deaths. Unlike ischemic strokes which are caused by the decreased blood flow they are caused by excessive bleeding into the brain or meninges due to the rupture of arteries and veins. It is important for a house officer to differentiate between ischemic and hemorrhagic stroke in order to provide proper healthcare to patients.
Today we will dive into both types of hemorrhagic stroke and explain them in detail along with their causes, risk factors, clinical presentation and treatment options. If you are also interested in ischemic stroke and it management click here. Hemorrhagic stroke is either Intra-parenchymal hemorrhage (IPH) or subarachnoid hemorrhage (SAH).
Intra-Parenchymal Hemorrhage:
It is also known as intracranial hemorrhage (ICH). It occurs when there is rupture of a blood vessels and the blood leaks into the brain parenchyma.
Risk Factors:
Risk factor for IPH is hypertension. It is one of the most common cause of IPH, the commonly involved sites are Putamen, Thalamus, Pons and Cerebral Hemispheres. Other factors include amyloid angiopathy, arteriovenous malformation, anticoagulation therapy, thrombolytic therapy, tumors and cocaine.
Clinical Presentation of Patient with Hemorrhagic Stroke:
Impairment of consciousness, vomiting, headache, seizures, progressively worsening neurological deficit of areas affected by the hemorrhage.
Diagnosis and Management of Patient with Hemorrhagic Stroke:
The best initial test for diagnosis of hemorrhagic stroke is CT scan, other than CT scan MRI and angiography can also be done.
In order to manage a patient with hemorrhagic stroke make sure that the airways are clear and patent. So airway protection and intubation should be done if the CGS score is less than 8. Avoid hyperthermia and head on the bed should be elevated to 30 to 45°. Reverse any coagulopathy that has occurred with administration of vitamin K and fresh frozen plasma. The target is to achieve INR of less than 1.4 or more than 100000 platelets. Platelet transfusion is done if the IPH is progressively worsening with time. If the patient is uremic then use DDAVP (desmopressin).
Hypertensive patient should have a strictly controlled BP of less than 160 systolic blood pressure. This can be achieved by Nicardipine or Lebetalol. Prophylactic anti-seizure therapy should also be started. Surgical decompression is indicated for large hemorrhages with clinical deterioration of the patient. Decompressive Hemicraniectomy can be considered as well.
Subarachnoid Hemorrhage (SAH):
SAH is most commonly caused by Berry aneurysm also called Saccular aneurysm. Other causes include vascular malformation, hematologic disturbances, tumors and traumatic hematoma. Berry aneurysm is the most common type of intracranial hemorrhage. It mostly occurs at the junction of anterior cerebral artery with anterior communicating artery (anterior circulation).
Causes of Subarachnoid Hemorrhage:
The main causes of SAH are Smoking, Hypertension, Polycystic kidney disease, Ehlers-Danlos syndrome type-4, Marfan syndrome and Neurofibromatosis type 1.
Clinical Presentation of Subarachnoid Hemorrhage:
Sudden onset of intensely painful thunderclap headache. The patient describe it as the worst pain of his or her life. There is loss of consciousness in less than half of the cases. There will be signs such as neck stiffness, photophobia and vomiting suggestive of meningeal irritation.
Diagnosis:
Non Contrast CT scan is the best initial test for the diagnosis of hemorrhagic stroke. It is very sensitive in the initial stage especially within first 12 hours of presentation.
Lumber puncture can be used as an investigation of choice. It is performed when CT is negative for hemorrhage or if more than 12 hours have elapsed. The lumber puncture results will show increased pressure, Xanthochromia due to RBC hemolysis, the RBCs count would be raised while the WBC may either be raised or normal. Glucose level will be normal and proteins level will be increased. The ratio of WBC to RBC is crucial for differentiating SAH from meningitis. The normal WBC to RBC ratio is 1:500-1000. This ratio is increased in patient with meningitis and is normal in patients with SAH.
Treatment of Hemorrhagic Stroke:
Controlling blood pressure is very important to prevent future incidences of hemorrhages. Calcium channel blocker “Nimodipine” prevent the occurrence of subsequent stroke and is prescribed as 30-60mg IV for 14 days than 360mg once a day for 7 days. Phenytoin should be given for seizures prophylaxis. Surgical clipping of the aneurysm is also an option if medication fails. A platinum coil can also inserted into the aneurysm via an endovascular procedure. Coiling is better than clipping due to fever complications. Coiling is now a days first choice procedure.
Complications and Their Treatment:
One of the compilations could be Obstructive Hydrocephalus and it is treated with a surgical shunt. Delayed cerebral ischemia can result and is treated with vasodilators. Hyponatremia can also occur and is treated with water restriction. Systemic complications such as chest infections or thrombosis of veins might take place as well.
How to be The Best From The Rest:
1. BP should not be reduced in an aggressive manner because it can worsen the brain perfusion. Use of IV Nicardipine, Labetalol or Clevidipine are deemed successful as they decrease blood pressure gradually and not sharply.
2. Never ever prescribe tissue plasmogen activator (tPA) to a patient with hemorrhagic stroke patient because it can be a fatal mistake. A CT scan is advised before administrating thrombolytics because hemorrhagic strokes can mimic ischemic strokes.
3. When bleeding occurs in the brain it increases the intracranial pressure to an extent that it can lead to herniation of brain. Which can prove fatal. So always watch for signs of herniation such as Cushing’s triad of hypertension, bradycardia, and irregular breathing. Use Mannitol or Hypertonic saline and refer the patient for neurosurgeon consultation immediately.
4. If a patient is already on Warfarin give PCC (prothrombin complex concentrate) with vitamin K. If the patient Is on DOACs give Idarucizumab or Andexanet.
5. If a young patient comes to you with hemorrhagic stroke it raises the suspicion of AVM, aneurysm, illicit drugs such as cocaine or amphetamines, vasculitis and coagulopathies.
6. The need for surgery in cases of hemorrhagic stroke depends upon size and location of the hemorrhage. If the size is more than 3 cm or if the bleed is compressing brainstem then decompression surgery is considered as the appropriate treatment. If the hemorrhage is deep seated than surgery is not preferred instead a conservative management approach is adopted.
Conclusion:
Hemorrhagic strokes are less common when compared to ischemic strokes but the risk of morbidity and mortality in cases of hemorrhagic is significantly high. It is essential for an house officer to be able to recognize someone with hemorrhagic stroke and to manage them at once. in order to provide effective healthcare it is important to understand the difference between intra-parenchymal and subarachnoid hemorrhages, their risk factors, clinical presentations, diagnostic tools, and treatment options. Every step in treatment plan can be lifesaving from securing air ways and controlling blood pressure to considering surgeries.
A good house officer knows that he or she should not rush in reducing blood pressure, avoids the use of thrombolytics in patients with hemorrhagic stroke and has the ability to think critically. That’s all for this blog if you liked this blog and want to know more about human body go to my website Medrizz.com.
FAQs:
What is the main difference between an ischemic and a hemorrhagic stroke?
Ischemic strokes occur due to a blockage in a blood vessel supplying the brain, while hemorrhagic strokes happen due to rupture of a vessel, causing bleeding into or around the brain tissue.
What are the two major types of hemorrhagic stroke?
Intra-parenchymal hemorrhage (IPH) – Bleeding into the brain tissue.
Subarachnoid hemorrhage (SAH) – Bleeding into the subarachnoid space.
What is the most common cause of IPH?
Hypertension is the leading cause of IPH, particularly affecting areas like the putamen, thalamus, pons, and cerebral hemispheres.
Why is a lumbar puncture important in diagnosing SAH?
It helps detect blood in the cerebrospinal fluid when the CT scan is inconclusive, especially if more than 12 hours have passed since symptom onset.
What is the first step in managing a hemorrhagic stroke patient in the ER?
Ensure airway protection. If the Glasgow Coma Scale (GCS) is <8, intubation should be performed. Also, elevate the head of the bed and manage blood pressure cautiously.
Which medication is used to prevent vasospasm after SAH?
Nimodipine, a calcium channel blocker, is used to prevent delayed cerebral ischemia due to vasospasm. It’s typically given for 21 days.