Hemorrhagic Stroke Summary

في
Hemorrhagic Stroke Summary

Hemorrhagic Stroke Summary

Must Memorize

Definition

Hemorrhagic stroke occurs when there is sudden bleeding in the brain. It is a type of intracranial hemorrhage.

Types

Intracranial hemorrhage includes:

  • Intracerebral hemorrhage (ICH): bleeding within the brain tissue
  • Intraventricular hemorrhage (IVH): bleeding within the ventricles
  • Subarachnoid hemorrhage (SAH): bleeding in the subarachnoid space
  • Subdural hematoma
  • Extradural hematoma

Epidemiology

  • Accounts for about 10-15% of all strokes.
  • ICH: ~10% of all strokes.
  • SAH: ~5% of all strokes.

Common Causes (Etiology)

  • Intracerebral Hemorrhage (ICH):
    • Hypertension is a common cause.
    • Other causes: Anticoagulants, Thrombocytopenia, Bleeding tendencies, Thrombolytic drugs, Vascular malformations (like AVM or aneurysm), bleeding into brain tumors or infarcts.
    • Cerebral amyloid angiopathy (commonest for spontaneous lobar ICH in patients >55 years).
    • Trauma is also a cause.
  • Subarachnoid Hemorrhage (SAH):
    • Rupture of an intracranial aneurysm is the commonest cause.
    • Rupture of an arterio-venous malformation (AVM).
    • Head trauma.

Risk Factors

  • ICH: Age > 65 years, Hypertension.
  • SAH: Hypertension, Smoking, Family history of SAH, Female sex, presence of Aneurysm.

Common Locations (ICH)

  • Most hypertensive brain hemorrhages occur in the basal ganglia (especially the putamen due to rupture of Charcot-Bouchard vessels).
  • Other possible locations: internal capsule, thalami, cerebellum, and brainstem.
  • Lobar hemorrhage (cerebral white matter) is usually related to causes other than hypertension.

Clinical Picture

  • Sudden onset is typical.
  • ICH:
    • Sudden onset of headache and/or loss of consciousness.
    • Vomiting occurs in 22-44%.
    • Seizures in 10%.
    • Nuchal rigidity is common.
    • Localizing signs (hemiplegia/hemiparesis, aphasia, homonymous hemianopia).
    • Symptoms of increased intracranial pressure (ICP) like headache and vomiting are common.
  • SAH:
    • Sudden, severe headache ("worst headache ever").
    • Classic triad: headache, depressed consciousness, stiff neck (meningism).
    • Vomiting, syncope, photophobia may occur.
    • Focal cranial nerve deficits (e.g., oculomotor palsy with posterior communicating artery aneurysm).

Diagnosis

  • Noncontrast CT Brain: Most used and preferred test. Superior to MRI for acute ICH. Blood appears as a hyperdense (white) lesion immediately in almost 100% of cases.
  • Lumbar Puncture (LP): Performed for suspected SAH if CT is negative. Findings: blood/xanthochromia in CSF, high pressure, increased protein, high RBC count.
  • Angiography (Conventional, CTA, or MRA): Important to locate aneurysm or AVM, especially if cause unclear on initial imaging.

Treatment

  • Medical emergency, often requiring ICU admission.
  • General Principles: ABC resuscitation and monitoring, Control BP, Control ICP.
  • Raised ICP Treatment: Hyperosmolar therapy (IV mannitol/hypertonic saline), hyperventilation, neuromuscular paralysis.
  • Anticonvulsants: Give if seizures occur. NOT recommended prophylactically in ICH. May be used prophylactically in SAH.
  • Treat coagulation factor deficiency or severe thrombocytopenia.
  • Steroids should be avoided in ICH.
  • ICH Specific:
    • Surgical evacuation (craniotomy) may be indicated for large (>30 ml), superficial hematomas with mass effect.
    • Conservative treatment often used for small hematomas or massive hemorrhages with established herniation/deep coma.
  • SAH Specific:
    • Primary goals: Prevent rebleeding and cerebral vasospasm.
    • Aneurysm obliteration: Surgical clipping or endovascular coiling.
    • Nimodipine (calcium channel blocker) used to prevent vasospasm.
    • Hydrocephalus treatment: CSF drainage or permanent shunt.

Important Concepts to Understand

Pathophysiology

  • ICH: Blood accumulates as a mass, dissecting/compressing brain tissue -> neuronal dysfunction & increased ICP. Rupture into ventricles/subarachnoid space -> acute hydrocephalus.
  • SAH: Blood in subarachnoid space -> chemical inflammation of meninges (headache, meningism). Vasospasm (narrowing of cerebral arteries) is a major complication -> delayed cerebral ischemia, significant neurological morbidity.

Clinical Progression

  • ICH: Patients may deteriorate rapidly in the initial few hours (20-40%).
  • SAH: Patients may lose consciousness then recover. Re-rupture of aneurysm is possible and often fatal.

Investigation Details

  • While CT detects acute blood, further imaging (contrast CT, MRI, Angiography - CTA/MRA/Conventional) is crucial to identify underlying causes (AVMs, aneurysms, cavernomas, tumors), especially for lobar hemorrhage or unclear etiology.
  • Conventional angiography remains the gold standard for detailed vascular anatomy/malformations.
  • Laboratory tests identify coagulopathies, bleeding tendencies, systemic conditions.

Treatment Strategies

  • Choice for underlying vascular lesion (aneurysm/AVM) depends on type, size, location, patient factors.
  • Options: Surgical (clipping, excision) and Endovascular (coiling, embolization, flow diverters).
  • Management of hydrocephalus (common complication): Temporary CSF drainage or permanent shunting.

تعليقات

إرسال تعليق