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Hemorrhagic Stroke

-20% of all strokes


Cerebral Hemorrhage

-subarachnoid hemorrhage
-intracerebral hemorrhage
-epidural hemorrhage
-subdural hemorrhage


Subarachnoid Hemorrhage

-bleeding into the subarachnoid space accounts for ~50 of cerebral hemorrhages


Parenchymal hemorrhage

-bleeding into the substance of the brain accounts for ~50 of cerebral hemorrhages


Etiologic Diagnosis: Hemorrhagic Stroke

-Berry aneurysm
-vascular malformation
-mycotic aneurysm
-bleeding diatheses
-anticoagulant complication
-congophilic angiopathy
-illicit drug use


Aneurysmal Subarachnoid Hemorrhage

-80% of SAH caused by rupture of berry or saccular aneurysm


Berry Aneurysms

-20% with aneurysm 5mm bleed at a rate of 1-3%/year best treated surgically or intravascular coils
-30,000 americans suffer a ruptured berry aneurysm yearly


Risk Factors for Subarachnoid (SAH) Hemorrhage

-tobacco use
-ethanol abuse
-oral contraceptives
-stimulant drugs (cocaine)
-low cholesterol
-genetics (polycystic kidneys, Marfan's syndrome)


Natural History of Subarachnoid (SAH) Hemorrhage

-10-15% die prior to ER
-25% die during next 3 months
~40% survivors have neurologic sequelae


Symptoms of Subarachnoid (SAH) Hemorrhage

-sudden, severe headache "worst of my life"
-rapid loss of consciousness in some but not all patients
-neck stiffness/pain, photophobia, phonophobia
-focal neurologic signs frequently minimal or absent


Signs of Subarachnoid Hemorrhage

-abnormal vital signs (elevated BP, arrhythmias)
-focal neurologic signs subtle or absent III nerve paresis (IC/PCom) aneurysm
Paraparesis - ACA aneurysm
Hemiparesis - MCA aneurysm
-Meningeal signs - usually present but may be subtle or delayed
-retinal hemorrhages


CT in Subarachnoid Hemorrhage

-most important diagnostic test to reveal blood in subarachnoid space or brain
-location of blood helps localize site of reupured aneurysm
-CT may be - if bleeding is slight or if CT delayed for several days
-CT - and you suspect SAH, perform lumbar puncture to rule out bleeding


Lumbar Puncture in Subarachnoid Hemorrhage

-if CT - for blood and SAH is suspected, perform lumbar puncture
-delay the LP for approximately 4 hrs after symptom (headache) onset
-if CSF appears bloody/discolored, immediately centrifuge it & examine for xanthochromia


Neuroradiology in Subarachnoid Hemorrhage

-MRI will reveal larger (>5mm) aneurysms
-gold standard is 4-vessel digital subtraction arteriography (DSA) for demonstrating one or more aneurysms (multiple could be polycystic kidney disease)


Treatment for Subarachnoid Hemorrhage

-definitive therapy for berry aneurysm is a combination of interventional radiology to coil some aneurysms with or without surgical clipping of the aneurysm


Parenchymal Hemorrhage

-most common causes for parenchymal brain hemorrhage are in decreasing frequency trauma, HTN, and arteriovenous malformations
-HTN causes microaneurysms called Charcot Bouchard aneurysms that eventually rupture
-HTN bleeds occur most frequently in the basal ganglia (30%), thalamus (20%), pons (5%), & cerebellum (10%)


Treatment for Parenchymal Hemorrhage

-AVM Hemorhage
-intravascular occlusion of AVM with coils, followed by surgical removal or gamma knife obliteration of AVM


Treatment for Parenchymal Hemorrhage

-HTN/traumatic hemorrhage (correct any bleeding problem (vit K, FFP, rFVIIa, Prothrombin complex concentration)
-reduce blood pressure to < 130mmHg
-monitor for & treat elevated intracranial pressure (hyperventilated, osmotic Rx, neurosurgical Rx) - maintain CPP b/w 60-80 Hg