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Hemorrhagic Stroke

• Approximately 70-80% of all strokes are

ischemic and 20-30% are hemorrhagic

• Hemorrhagic stroke is defined as an acute

neurologic injury resulting from bleeding in

the brain

• There are two distinct types of hemorrhagic

stroke: intracerebral hemorrhage (ICH) and

subarachnoid hemorrhage (SAH).

Hemorrhagic Stroke

Hemorrhagic Stroke

• SAH accounts for 3-5% of all strokes.

• Classically the patient experiences the worst

headache of his or her life. One in 5

patients report a less severe headache in the

hours or days preceding the event.

• The event may be accompanied by focal

neurologic signs, nausea/vomiting, loss of

consciousness, seizure.

Hemorrhagic Stroke

• The most common cause of spontaneous SAH is the rupture of a cerebral aneurysm, accounting for about 85% of SAHs.

• Aneurysms tend to occur at the branch points of cerebral vessels.

• The 30-day mortality is in the range of 33 to 45%.

Hemorrhagic Stroke

• Cerebral aneurysms are present in about 2% of the

population

• Overall the annual risk of rupture is about 0.7%

• Rupture risk is related to aneurysm size and

location.

• The risk of rupture increases significantly for

aneurysms greater than 7 mm in diameter and for

those arising from the posterior communicating

arteries or posterior circulation.

Hemorrhagic Stroke

• 80-85% of aneurysms are located in the

anterior circulation, commonly at the

origins of the posterior or anterior

communicating arteries or the middle

cerebral artery bifurcation.

• Posterior circulation aneurysms most often

occur at the basilar tip or posterior-inferior

cerebellar artery origin.

Hemorrhagic Stroke

Hemorrhagic Stroke

• The factors that strongly influence outcome after

SAH can be divided into patient factors, aneurysm

factors and institutional factors.

• Of the patient factors, by far the most important

determinant is the deleterious effect of acute SAH

on the brain documented by the worst Hunt and

Hess Grade.

Hemorrhagic Stroke

• Hunt and Hess Grade

• Grade 1: Asymptomatic or mild headache and slight

nuchal rigidity

• Grade 2: Moderate to severe headache, stiff neck, no

neurologic deficit except cranial nerve palsy

• Grade 3: Drowsy or confused, mild focal neurologic

deficit

• Grade 4: Stupor, moderate or severe hemiparesis

• Grade 5: Deep coma, decerebrate posturing

Hemorrhagic Stroke

• Other patient factors include age and medical co-

morbidities, such as hypertension, atrial

fibrillation, congestive heart failure, coronary

heart disease, and renal disease.

• Vasospasm severity, re-hemorrhage, and acute

hydrocephalus are also significantly related to

outcome.

• Aneurysm factors include size and location in the

posterior circulation.

Hemorrhagic Stroke

• Institutional factors include the availability of endovascular services and the volume of SAH patients treated.

• With aggressive management of SAH including emergency ventricular drain placement, ultraearly aneurysm repair, multidisciplionary medical care involving intensivists, and endovascular therapies for vasospasm such as selective infusion of intra-arterial vasodilators and balloon angioplasty approximately half of Hunt and Hess grade V survivors had cognitive deficits only slightly reduced compared with the normative population mean.

Hemorrhagic Stroke

• Patients with a good cognitive outcome

after a severe SAH were significantly

younger (median age 46 versus 52 years),

had more years of education (13 versus 9

years) and had smaller cerebral ventricular

scores.

Hemorrhagic Stroke

• The mainstay of SAH diagnosis is the noncontrast

head CT.

• In the 12 hours after SAH, the sensitivity of CT

for SAH is 98% to 100%, declining to 93% after

24 hours and to 57% to 85% after 6 days.

• Because the diagnostic sensitivity of CT scanning

is not 100%, a lumbar puncture should be

performed if the clinical presentation is suspicious

for a SAH.

Hemorrhagic Stroke

• Cerebral angiography

is currently the

standard for

diagnosing cerebral

aneurysm as the cause

of SAH

Hemorrhagic Stroke

• The selection of surgery versus coiling

depends on several factors including:

• Aneurysm location

• Presence of a large hematoma

• Aneurysm size

• Aneurysm neck size

• Patient co-morbidities

Hemorrhagic Stroke

• Intracerebral Hemorrhage (ICH) causes 10-

15% of first-ever strokes, with a 30-day

mortality rate of 35% to 52%; half of the

deaths occur in the first two days.

• 20% of ICH patients are independent at 6

months.

Hemorrhagic Stroke

• Causes of ICH• Cerebral aneurysms

• Cerebral arteriovenous

malformations

• Cavernous

malformations

• Moya-moya disease

• Vasculitis

• Hypertension

• Amyloid angiopathy

• Anticoagulants/ antiplatelet agents

• Recreational drugs

• Post-infarction

• Blood dyscrasias

• Idiopathic

• *Brain tumors

• *Unrecognized trauma

Hemorrhagic Stroke

• Hospital admissions for ICH have increased

by 18% over the last ten years

• Increases in the number of elderly people

• Lack of adequate blood pressure control

• Increasing use of anticoagulants and antiplatelet

agents

Hemorrhagic Stroke

• Rapid recognition and diagnosis of ICH are essential because of its frequently rapid progression during the first several hours.

• The classic presentation includes the onset of a focal neurologic deficit, which progresses over minutes to hours.

• This smooth progression of a focal deficit over a few hours is uncommon in ischemic stroke and rare in SAH.

Hemorrhagic Stroke

Initial CT 2’ 45” later

Hemorrhagic Stroke

• Brain imaging is a crucial part of the emergent evaluation.

• CT and MRI have equal ability to identify the presence of acute ICH, its size and location.

• Indications for cerebral angiography include SAH, abnormal calcifications, obvious vascular abnormalities and isolated intraventricular hemorrhage (IVH).

Hemorrhagic Stroke

• Hypertensive vasculopathy is the most common

cause of ICH.

• The underlying mechanism is related to the effects

of systemic blood pressure on small penetrating

arteries that arise from major intracranial vessels.

• In response to hypertension, these small vessels

can develop intimal hyperplasia, intimal

hyalinization and medial degeneration, which

predispose them to focal necrosis and rupture.

Hemorrhagic Stroke

• The classic location of hypertensive hemorrhages reflects the territories supplied by these small perforators, with 60-65% in the putamen and internal capsule, 15-25% in the thalamus and 5-10% in the pons.

Hemorrhagic Stroke

• Cerebral amyloid angiopathy (CAA) is another common cause of ICH.

• Strongly associated with age, rarely seen in patients under 60 years and progressively increases in incidence after the age of 65.

• CAA is characterized by the deposition of amyloid beta-peptide in the small and medium-sized vessels of the cortex with relative sparing of vessels in the basal ganglia, white matter, and posterior fossa.

• Affected vessels undergo fibrinoid degeneration, necrosis and microaneurysm formation.

Hemorrhagic Stroke

• CAA-related

hemorrhages tend to

occur in the cortex

causing lobar

hemorrhages more

often in the temporal

and occipital lobes.

Hemorrhagic Stroke

• Treatment of ICH

• The observation that substantial ongoing

bleeding occurred in patients with ICH and was

linked to neurological deterioration led to

interest in the control of blood pressure and the

use of activated factor VII.

Hemorrhagic Stroke

• Guidelines for the Management of Blood

Pressure

• MAP <110 or SBP<160 and >90 for the first

24-48 hours if no ICP monitor present

• Keep CPP >70 if ICP monitor present

Hemorrhagic Stroke

• Ongoing trials have reported that aggressive reduction of blood pressure to less than 140 mm Hg probably decreases the rate of hematoma enlargement without increasing adverse events.

• However, because the effect on clinical outcome has not been fully assessed, the more conservative BP targets should be followed.

• Caution is advised about lowering blood pressure too aggressively without concomitant management of CPP.

Hemorrhagic Stroke

• Management of ICP in ICH

• The European Stroke Initiative (EUSI)

guidelines recommend monitoring of

intracranial pressure for patients who need

mechanical ventilation.

• Both the American Stroke Association (ASA)

and EUSI recommend selective use of

mannitol, hypertensive saline and short-term

hyperventilation to maintain the CPP>70.

Hemorrhagic Stroke

• With increasing use of warfarin, oral

anticoagulation (OAC) associated ICH

represents an increasing proportion (up to

17%) of ICH cases and carries a very high

mortality (up to 67%).

• No matter what the indication for warfarin,

the benefits of initial reversal after ICH

always outweigh the risks of stopping OAC.

Hemorrhagic Stroke

• Warfarin doubles ICH mortality

• Warfarin increases risk of hematoma

expansion (OR 6.22)

• Hematoma expansion occurs over more

prolonged time course

Hemorrhagic Stroke

• Reversal of Anticoagulation

• An INR of 1.4 in any ICH patient should be

considered life-threatening.

• Guidelines from US, UK and Australia

recommend

• Prothrombin complex concentrate (PCC)

• Vitamin K

• Fresh Frozen Plasma

Hemorrhagic Stroke

• Vitamin K promotes endogenous clotting factor

synthesis but takes 6h to have an effect.

• PCC has several advantages over FFP including

no need for thawing or compatibility testing,

smaller volumes and higher factor IX levels.

• Although FVIIa can rapidly correct the INR, it

does not replenish all of the vitamin K-dependent

factors and therefore, may not restore thrombin

generation as well as PCC.

• Seizures after ICH

• Incidence is between 4.6% and 8.2%.

• The routine use of anti-epileptics is not recommended because of uncertainties about their efficacy and outcomes.

• Subclinical seizures occur is up to 30% of patients after ICH. Continuous EEG monitoring should be considered in ICH patients with a decreased level of consciousness that is out of proportion to the amount of brain injury.

Hemorrhagic Stroke

Hemorrhagic Stroke

• Venous Thromboembolism Prophylaxis

• Symptomatic and asymptomatic deep vein thrombosis

occurs in 3.7% and 40% of ICH patients respectively.

• All patients with reduced mobility should have SCDs.

• Low molecular weight heparin should be introduced 1-

4 days after the onset of ICH, once cessation of

bleeding has been demonstrated.

Hemorrhagic Stroke

• Management of Blood Glucose

• Maintain euglycemia as with other critically ill

patients (<140 or 150 mg/dl?)

• Avoid large swings in blood glucose

Hemorrhagic Stroke

• Neurosurgery

• Surgical Trial in Intracerebral Hemorrhage (STICH) randomized 1033 patients with supratentorial ICH to surgery within 72 h or to conservative management and demonstrated no outcome benefit from surgery.

• STITCH II is investigating the outcome of surgery for lobar hematomas <1 cm from the surface or the brain in patients without IVH.

• Several minimally invasive surgery trials which combine stereotactic guidance of catheters combined with thrombolytic enhanced hematoma evacuation are ongoing.

Hemorrhagic Stroke

• Recommendation for

Surgical Approaches

• Patients with

Cerebellar hemorrhage

>3cm who are

deteriorating

neurologically or who

have brain stem

compression should

have surgical removal

of the clot.

Hemorrhagic Stroke

• For patients with lobar

clots within 1 cm of

the surface, evacuation

of supratentorial ICH

by standard

craniotomy should be

considered.

Hemorrhagic Stroke

• Ventricular drainage should be considered

in all stuporous or comatose patients with

intraventricular hemorrhage and acute

hydrocephalus.

Hemorrhagic Stroke

Hemorrhagic Stroke

• Prognosis of ICH

• 60% of patients with an ICH Score of 0, 50%

with an ICH score of 1, 15% with an ICH score

of 2, 10% with an ICH score of 3 have a

modified Rankin score (mRS) of 1 or 2 at 12

months.

Hemorrhagic Stroke

• In summary, the prevention of clot

expansion is the best way of improving

outcomes from ICH.

• The most effective way of preventing ICH

is blood pressure control and avoiding over

anticoagulation.

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