HEMORRHAGIC STROKE

Learning Objectives

⚫ 1. Discuss factors associated with hemorrhagic

stroke.
⚫ 2. Recognize signs and symptoms of hemorrhagic
stroke.
⚫ 3. Differentiate types of hemorrhagic stroke and
their corresponding management.
 HEMORRHAGIC STROKE

⚫ Occurs when a blood vessel bursts inside the

brain.

FACTORS:
1. Uncontrolled high blood pressure
2. Aneurysms
3. Arteriovenous malformation(AVM)
4. Metastatic cancer
5. Cerebral amyloid angiopathy (Congophilic
Angiopathy)
6. Conditions or medications
AV Malformation
 Forms of Hemorrhagic Stroke

1. Intracerebral Hemorrhage
Most common in patients with
hypertension & cerebral
atherosclerosis
⚫ Bleeding occurs most commonly
in the cerebral lobes, basal
ganglia, thalamus, brainstem
& cerebellum
 2. Intracranial (Cerebral) Aneurysm

⚫ dilation/ballooning of the walls of a cerebral

artery
⚫ Tend to increase in size causing increasing pressure
against adjacent CNS tissue & a danger of rupture.
⚫ Cause: unknown
⚫ Onset: usually sudden and without warning
Precipitating/Predisposing Factors
1. Atherosclerosis
2. Congenital defect of the vessel wall
3. Hypertensive vascular disease
4. Head trauma
5. Advancing age
 Classification of Aneurysm

⚫ SACCULAR; rounded
berrylike outpouchings
that arise from arterial
bifurcation points

⚫ FUSIFORM; a
spindle-shaped
aneurysm; AKA
atherosclerotic
aneurysm

⚫ Ruptured aneurysm
⚫ Any artery within the brain can be the site of
aneurysm; usually occur at the bifurcations of the
large arteries at the CIRCLE OF WILLIS
⚫ Most commonly affected:
1. Internal carotid artery (ICA)
2. Anterior cerebral artery (ACA)
3. Anterior communicating artery (ACoA)
4. Posterior communicating artery (PCoA)
5. Posterior cerebral artery (PCA)
6. Middle cerebral artery (MCA)
 Surgical Intervention

⚫ LIGATION or
CLIPPING of the
ANEURYSM
 3. Arteriovenous Malformations (AVMS)

⚫ Abnormal connections between arteries and

veins
⚫ Usually caused by an abnormality in embryonal
development that leads to a tangle of arteries & veins
in the brain that lacks capillary bed.
⚫ Common cause of hemorrhagic stroke in young
people.
AVM’s
 4. Subarachnoid Hemorrhage

⚫ Hemorrhage into the

subarachnoid space
⚫ may occur as a result
of an AVM,
intracranial
aneurysm, trauma,
or hypertension.
CLIPS
 PATHOPHYSIOLOGY

Cerebral aneurysm or AVM ruptures

↓
Hemorrhage into the cranial subarachnoid space
↓
Normal brain metabolism is disrupted by:
1. The brain’s exposure to blood
2. An increase in ICP
↓
Compression & injury to brain tissue
↓
vasospasm; ischemia to the brain
 Clinical Manifestations

⚫ Neurologic deficits: similar to ISCHEMIC

STROKE
⚫ Motor, sensory, cranial nerve, cognitive loss
⚫ Severe headache; Vomiting
⚫ Early & sudden change in LOC
⚫ Seizures due to frequent brain stem involvement
⚫ Aneurysm/ AVM; sudden unusually severe
headache & LOC for a variable period of time; pain &
nuchal rigidity
⚫ Visual disturbances; tinnitus, dizziness , hemiparesis
⚫ Severe bleeding followed rapidly by coma &
death
 Prognosis

⚫ Depends on the neurologic condition of the

patient, the patient’s age, associated diseases
& the extent & location of the hemorrhage or
intracranial aneurysm
 Diagnostic tests

⚫ Computed Tomography scan

⚫ Magnetic Resonance Imaging
⚫ Cerebral angiography
⚫ Lumbar puncture
⚫ Other tests may include:
⚫ CBC, PT, PTT, CSF exam
Prevention

⚫ Primary prevention
✔ Manage hypertension &
other risk factors
⚫ Stroke risk screening
 Complications

1. Cerebral hypoxia & decreased blood flow to area of

injury
2. Cerebral vasospasm
⚫ Increased vascular resistance
⚫ Intensified headaches, decreased LOC,
Cerebral Vasospasm
3. Increased intracranial pressure;

4. Hypertension
⚫ Most common cause of intracerebral hemorrhage
⚫ Antihypertensive therapy (nicardipine,
nitroprusside, hydralazine)

5. Hydrocephalus & rebleeding

 Medical Management

Goals of treatment
⚫ Save the person's life
⚫ Relieve symptoms
⚫ Repair the cause of bleeding
⚫ Prevent complications
⚫ START REHABILITATION THERAPY as soon as
possible
❖ Craniotomy
 IMMEDIATE TREATMENT IN THE HOSPITAL

⚫ Pt. is placed in ICU,

closely monitored
⚫ Pay careful attention to
breathing
⚫ Carefully control BP
⚫ Drugs to control brain
swelling
⚫ Medications for
Headaches
⚫ Seizure medications
⚫ Rest in bed and
avoid activities that
may increase ICP
⚫ Nutrients and fluids
may be necessary
The heart is deceitful above all things, and
desperately sick; who can understand it?

Jeremiah 17:9