Hemorrhagic stroke occurs when a blood artery ruptures and causes bleeding into the brain. Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are the primary kinds of hemorrhagic strokes.
Intracerebral Hemorrhage (ICH): This type of hemorrhagic stroke happens when a blood vessel ruptures and bleeds into the brain tissue. The bleeding causes damage to the surrounding brain cells, and the accumulation of blood creates pressure on the brain, leading to further injury.
Subarachnoid Hemorrhage (SAH): The subarachnoid space, or the gap between the brain and the delicate tissues covering it, is where SAH arises when bleeding occurs. An aneurysm rupture, a weakened area in a blood vessel wall, causes most cases of SAH. The sudden release of blood into the subarachnoid space can cause severe headaches, neck stiffness, and neurological symptoms.
Epidemiology
10% to 20% of all strokes occur annually due to hemorrhagic stroke. Hemorrhage occurs in 8-15% of stroke cases in the United States, UK, and Australia; however, in Japan and Korea, that number rises to 18-24%. The incidence ranges from 12% to 15% per 100,000 people annually. The prevalence rises with age and is more prevalent in males.
The prevalence is rising worldwide, mostly in Asian and African nations. According to Japanese research, ICH is less common when hypertension is under control. In high-income countries, the case fatality rate ranges from 25% to 30%, whereas it ranges from 30% to 48% in low- and middle-income nations.
Anatomy
Pathophysiology
The primary pathophysiological processes include:
Vascular Injury: Hemorrhagic stroke can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, arteriovenous malformations, and blood clotting disorders.
Bleeding and Hematoma Formation: The hematoma can enlarge within a few hours to 12 hours after the initial bleed. Perihematomal edema, the swelling around the hematoma, increases within 24 hours, peaks around five to six days, and can persist for up to 14 days.
Mass Effect and Increased Intracerebral Pressure (ICP): The presence of hematoma causes compression of the brain tissue and increases the ICP.
Excitotoxicity and Neurotransmitter Imbalance: The disruption of neuronal function can lead to an imbalance of neurotransmitters, such as glutamate. Excessive release of glutamate and impaired clearance can result in excitotoxicity, causing further damage to neurons.
Inflammation and Secondary Injury: Hemorrhagic stroke triggers an inflammatory response in the brain. Inflammatory cells, such as microglia, are activated, releasing pro-inflammatory mediators. This inflammatory cascade can contribute to secondary injury, including damage to the blood-brain barrier.
Cerebral Ischemia and Hypoperfusion: Hemorrhagic stroke can also lead to decreased blood flow and ischemia in the surrounding brain tissue.
Etiology
The primary causes of hemorrhagic stroke include:
Hypertension (High Blood Pressure): Blood vessel walls become more susceptible to perforation and hemorrhage because of prolonged hypertension.
Cerebral Amyloid Angiopathy (CAA): CAA is a condition characterized by the accumulation of amyloid protein in the walls of blood vessels in the brain.
Tumors and subarachnoid hemorrhage: Certain tumors, including glioblastoma, metastasis, lymphoma, meningioma, pituitary adenoma, and hemangioblastoma, are more prone to bleeding and can cause intracerebral hemorrhage.
Genetics
Prognostic Factors
Poor prognostic factors in Intracerebral hemorrhage: Several variables, such as unconsciousness at the time of presentation, an extensive hematoma with a volume larger than 30 ml, posterior fossa hemorrhage, elderly age (>80 years), high blood sugar, and chronic renal disease, suggest a poor prognosis in ICH.
Stroke unit care: The American Stroke Association (ASA) advises that individuals with intracerebral hemorrhage must be monitored and managed in a special stroke unit. It has been shown that specialized stroke units enhance results and lower death.
Functional outcomes: Only around 20% of intracerebral hemorrhage patients gain independence at six months. In cases of severe hemisphere damage or brainstem involvement, survivors may experience locked-in syndrome or a permanent vegetative state.
Intracerebral hemorrhage score: The intracerebral hemorrhage score, found by Hemphill et al., is a predictive tool for estimating mortality in ICH. It assigns points based on various factors:
Glasgow Coma Scale (GCS) score: GCS 3 to 4 get two points, GCS 5 to 12 gets one point, and GCS 13 to 15 gets none.
Age: one point for those over 80, zero points for people under 80.
one point for an infratentorial (posterior fossa) hemorrhage, zero points for a supratentorial hemorrhage.
The projected thirty-day mortality risk is based on the overall score. The death rates are as follows: 100% for scores 5 and 6, 97% for scores 4, 72% for scores 3, 26% for scores 2, 13% for scores 1 and 2,and 0% for scores 0 and 1
Clinical History
CLINICAL HISTORY
Age group: The clinical presentation of hemorrhagic stroke may differ among different age groups.
Younger adults: Hemorrhagic stroke in younger adults may be associated with underlying conditions such as vascular malformations, drug abuse (e.g., cocaine), or specific genetic disorders.
Older adults: Hemorrhagic stroke is more prevalent in older adults, particularly those over 55.
Physical Examination
The critical components of the physical examination:
Vital signs: Assessing vital signs provides crucial information about the patient’s overall condition and helps monitor any signs of instability.
Blood pressure: High blood pressure is a common risk factor for hemorrhagic stroke, so measuring blood pressure is essential.
Heart rate and rhythm: Irregularities or abnormalities in heart rate and rhythm may indicate underlying cardiovascular conditions.
Neurological examination: Evaluating the patient’s neurological function is vital to identify any focal deficits or signs of increased intracerebral pressure.
Mental status: Assessing the patient’s level of consciousness, orientation, and cognitive function.
Cranial nerves: Testing the function of various cranial nerves, including visual acuity, pupillary responses, facial movements, and eye movements.
Motor function: Assessing muscle strength, tone, and coordination in all extremities.
Cardiovascular examination: Evaluating the cardiovascular system helps identify underlying conditions or complications.
Auscultation of the heart: Listening for abnormal heart sounds, murmurs, or irregular rhythms.
Peripheral pulses: Assessing the strength and regularity of pulses in the extremities.
Respiratory examination: Assessing the patient’s respiratory function helps monitor oxygenation and identify respiratory complications.
Respiratory rate: Counting the patient’s breaths per minute.
Auscultation of the lungs: Listening for abnormal breath sounds, such as crackles or diminished breath sounds.
Age group
Associated comorbidity
Associated comorbidity or activity:
Comorbidities or engagement in certain activities can impact the clinical presentation of hemorrhagic stroke.
Hypertension: Uncontrolled hypertension can lead to vessel wall damage and increase the risk of bleeding in the brain.
Coagulopathy: Conditions that affect the blood’s ability to clot, such as hemophilia, liver disease, or anticoagulant medications, can increase the risk of hemorrhagic stroke.
Trauma: Traumatic brain injury (TBI) can result in intracerebral bleeding, leading to stroke symptoms.
Associated activity
Acuity of presentation
Acuity of presentation:
Sudden onset: Hemorrhagic stroke often presents with a sudden onset of symptoms. Patients may describe the sudden onset of severe headache, accompanied by neurological deficits such as weakness, numbness, difficulty speaking, or loss of consciousness.
Rapid progression: The symptoms of hemorrhagic stroke can rapidly progress within minutes to hours after the onset.
Thunderclap headache: A thunderclap headache, a severe and sudden-onset headache, can be a characteristic feature of hemorrhagic stroke.
Differential Diagnoses
DIFFERENTIAL DIAGNOSIS
The differential diagnoses of hemorrhagic stroke are as follows:
Acute hypertensive crisis: Uncontrolled high blood pressure can lead to bleeding in the brain and present with symptoms like hemorrhagic stroke.
Pituitary apoplexy: This condition occurs when there is bleeding in the pituitary gland, typically associated with an underlying pituitary tumor.
Cerebral venous thrombosis: It is the formation of a blood clot in the cerebral veins, impeding blood drainage from the brain.
Dural sinus thrombosis: Dural sinuses are large veins that drain blood from the brain. Thrombosis or blockage of these sinuses can lead to symptoms resembling hemorrhagic strokes.
Cervical artery dissection: Dissection of the carotid or vertebral arteries can cause bleeding and present with symptoms like stroke.
Reversible cerebral vasoconstrictive syndrome (RCVS): RCVS is characterized by sudden constriction and narrowing of the brain’s blood vessels, leading to headaches, neurological symptoms, and, in some cases, bleeding.
Hemorrhagic neoplasms: Certain tumors, such as brain tumors or metastatic lesions, can cause bleeding and present with symptoms resembling hemorrhagic stroke.
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
TREATMENT PARADIGM
Modification of Environment:
Admission to a dedicated stroke unit: Patients with hemorrhagic stroke should be admitted to a specialized stroke unit to receive appropriate monitoring and management.
Administration of Pharmaceutical Agents:
Blood pressure management: Medications may be administered to lower and stabilize blood pressure within an appropriate range.
Anti-seizure medications: Prophylactic use of anti-seizure medications may be considered, especially in cases of intracerebral hemorrhage.
Hemostatic therapy: In specific cases, such as when there is a coagulopathy or anticoagulant-related bleeding, reversal agents or other hemostatic agents may be administered to control bleeding.
Intervention with Procedures:
Surgical intervention: In some instances, neurosurgical procedures may be required to evacuate the hematoma, relieve the mass effect on the brain, or repair an underlying vascular abnormality.
Endovascular procedures: Minimally invasive techniques, such as coiling or embolization, may be employed to treat certain types of hemorrhagic strokes caused by vascular abnormalities.
Phases of Management:
Acute phase: In the acute phase, the primary focus is stabilizing the patient, managing the airway, breathing, and circulation, and conducting neurologic assessments.
Subacute phase: After stabilizing the patient’s condition, further diagnostic evaluations and treatment planning are carried out.
Recovery and rehabilitation phase: As the patient progresses, rehabilitation becomes an essential management aspect.
For mild-to-moderate bleeding in adults having surgery, topical fibrin sealant is recommended as an adjuvant to hemostasis when typical surgical procedures (such as sutures, ligatures, and cauteries) are not practical or effective in controlling the bleeding
Depending on the size of the bleeding area, different amounts are needed to stop the bleeding
Not more than 3 g in total each procedure
Direct application dose is given for the treatment of the maximum bleeding surface area:
• For 25 sqm, it is a 0.5 g vial
• For 50 sqm, it is 1 g vial
• For 100 sqm, it is a 2 g vial
The dosage for the Raplixa Spray device is 0.5 g vial for 50 sq cm, 1 g vial for 100 sq cm, and 2 g vial for 200 sq cm
Hemorrhagic stroke occurs when a blood artery ruptures and causes bleeding into the brain. Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are the primary kinds of hemorrhagic strokes.
Intracerebral Hemorrhage (ICH): This type of hemorrhagic stroke happens when a blood vessel ruptures and bleeds into the brain tissue. The bleeding causes damage to the surrounding brain cells, and the accumulation of blood creates pressure on the brain, leading to further injury.
Subarachnoid Hemorrhage (SAH): The subarachnoid space, or the gap between the brain and the delicate tissues covering it, is where SAH arises when bleeding occurs. An aneurysm rupture, a weakened area in a blood vessel wall, causes most cases of SAH. The sudden release of blood into the subarachnoid space can cause severe headaches, neck stiffness, and neurological symptoms.
10% to 20% of all strokes occur annually due to hemorrhagic stroke. Hemorrhage occurs in 8-15% of stroke cases in the United States, UK, and Australia; however, in Japan and Korea, that number rises to 18-24%. The incidence ranges from 12% to 15% per 100,000 people annually. The prevalence rises with age and is more prevalent in males.
The prevalence is rising worldwide, mostly in Asian and African nations. According to Japanese research, ICH is less common when hypertension is under control. In high-income countries, the case fatality rate ranges from 25% to 30%, whereas it ranges from 30% to 48% in low- and middle-income nations.
The primary pathophysiological processes include:
Vascular Injury: Hemorrhagic stroke can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, arteriovenous malformations, and blood clotting disorders.
Bleeding and Hematoma Formation: The hematoma can enlarge within a few hours to 12 hours after the initial bleed. Perihematomal edema, the swelling around the hematoma, increases within 24 hours, peaks around five to six days, and can persist for up to 14 days.
Mass Effect and Increased Intracerebral Pressure (ICP): The presence of hematoma causes compression of the brain tissue and increases the ICP.
Excitotoxicity and Neurotransmitter Imbalance: The disruption of neuronal function can lead to an imbalance of neurotransmitters, such as glutamate. Excessive release of glutamate and impaired clearance can result in excitotoxicity, causing further damage to neurons.
Inflammation and Secondary Injury: Hemorrhagic stroke triggers an inflammatory response in the brain. Inflammatory cells, such as microglia, are activated, releasing pro-inflammatory mediators. This inflammatory cascade can contribute to secondary injury, including damage to the blood-brain barrier.
Cerebral Ischemia and Hypoperfusion: Hemorrhagic stroke can also lead to decreased blood flow and ischemia in the surrounding brain tissue.
The primary causes of hemorrhagic stroke include:
Hypertension (High Blood Pressure): Blood vessel walls become more susceptible to perforation and hemorrhage because of prolonged hypertension.
Cerebral Amyloid Angiopathy (CAA): CAA is a condition characterized by the accumulation of amyloid protein in the walls of blood vessels in the brain.
Tumors and subarachnoid hemorrhage: Certain tumors, including glioblastoma, metastasis, lymphoma, meningioma, pituitary adenoma, and hemangioblastoma, are more prone to bleeding and can cause intracerebral hemorrhage.
Poor prognostic factors in Intracerebral hemorrhage: Several variables, such as unconsciousness at the time of presentation, an extensive hematoma with a volume larger than 30 ml, posterior fossa hemorrhage, elderly age (>80 years), high blood sugar, and chronic renal disease, suggest a poor prognosis in ICH.
Stroke unit care: The American Stroke Association (ASA) advises that individuals with intracerebral hemorrhage must be monitored and managed in a special stroke unit. It has been shown that specialized stroke units enhance results and lower death.
Functional outcomes: Only around 20% of intracerebral hemorrhage patients gain independence at six months. In cases of severe hemisphere damage or brainstem involvement, survivors may experience locked-in syndrome or a permanent vegetative state.
Intracerebral hemorrhage score: The intracerebral hemorrhage score, found by Hemphill et al., is a predictive tool for estimating mortality in ICH. It assigns points based on various factors:
Glasgow Coma Scale (GCS) score: GCS 3 to 4 get two points, GCS 5 to 12 gets one point, and GCS 13 to 15 gets none.
Age: one point for those over 80, zero points for people under 80.
one point for an infratentorial (posterior fossa) hemorrhage, zero points for a supratentorial hemorrhage.
The projected thirty-day mortality risk is based on the overall score. The death rates are as follows: 100% for scores 5 and 6, 97% for scores 4, 72% for scores 3, 26% for scores 2, 13% for scores 1 and 2,and 0% for scores 0 and 1
CLINICAL HISTORY
Age group: The clinical presentation of hemorrhagic stroke may differ among different age groups.
Younger adults: Hemorrhagic stroke in younger adults may be associated with underlying conditions such as vascular malformations, drug abuse (e.g., cocaine), or specific genetic disorders.
Older adults: Hemorrhagic stroke is more prevalent in older adults, particularly those over 55.
The critical components of the physical examination:
Vital signs: Assessing vital signs provides crucial information about the patient’s overall condition and helps monitor any signs of instability.
Blood pressure: High blood pressure is a common risk factor for hemorrhagic stroke, so measuring blood pressure is essential.
Heart rate and rhythm: Irregularities or abnormalities in heart rate and rhythm may indicate underlying cardiovascular conditions.
Neurological examination: Evaluating the patient’s neurological function is vital to identify any focal deficits or signs of increased intracerebral pressure.
Mental status: Assessing the patient’s level of consciousness, orientation, and cognitive function.
Cranial nerves: Testing the function of various cranial nerves, including visual acuity, pupillary responses, facial movements, and eye movements.
Motor function: Assessing muscle strength, tone, and coordination in all extremities.
Cardiovascular examination: Evaluating the cardiovascular system helps identify underlying conditions or complications.
Auscultation of the heart: Listening for abnormal heart sounds, murmurs, or irregular rhythms.
Peripheral pulses: Assessing the strength and regularity of pulses in the extremities.
Respiratory examination: Assessing the patient’s respiratory function helps monitor oxygenation and identify respiratory complications.
Respiratory rate: Counting the patient’s breaths per minute.
Auscultation of the lungs: Listening for abnormal breath sounds, such as crackles or diminished breath sounds.
Associated comorbidity or activity:
Comorbidities or engagement in certain activities can impact the clinical presentation of hemorrhagic stroke.
Hypertension: Uncontrolled hypertension can lead to vessel wall damage and increase the risk of bleeding in the brain.
Coagulopathy: Conditions that affect the blood’s ability to clot, such as hemophilia, liver disease, or anticoagulant medications, can increase the risk of hemorrhagic stroke.
Trauma: Traumatic brain injury (TBI) can result in intracerebral bleeding, leading to stroke symptoms.
Acuity of presentation:
Sudden onset: Hemorrhagic stroke often presents with a sudden onset of symptoms. Patients may describe the sudden onset of severe headache, accompanied by neurological deficits such as weakness, numbness, difficulty speaking, or loss of consciousness.
Rapid progression: The symptoms of hemorrhagic stroke can rapidly progress within minutes to hours after the onset.
Thunderclap headache: A thunderclap headache, a severe and sudden-onset headache, can be a characteristic feature of hemorrhagic stroke.
DIFFERENTIAL DIAGNOSIS
The differential diagnoses of hemorrhagic stroke are as follows:
Acute hypertensive crisis: Uncontrolled high blood pressure can lead to bleeding in the brain and present with symptoms like hemorrhagic stroke.
Pituitary apoplexy: This condition occurs when there is bleeding in the pituitary gland, typically associated with an underlying pituitary tumor.
Cerebral venous thrombosis: It is the formation of a blood clot in the cerebral veins, impeding blood drainage from the brain.
Dural sinus thrombosis: Dural sinuses are large veins that drain blood from the brain. Thrombosis or blockage of these sinuses can lead to symptoms resembling hemorrhagic strokes.
Cervical artery dissection: Dissection of the carotid or vertebral arteries can cause bleeding and present with symptoms like stroke.
Reversible cerebral vasoconstrictive syndrome (RCVS): RCVS is characterized by sudden constriction and narrowing of the brain’s blood vessels, leading to headaches, neurological symptoms, and, in some cases, bleeding.
Hemorrhagic neoplasms: Certain tumors, such as brain tumors or metastatic lesions, can cause bleeding and present with symptoms resembling hemorrhagic stroke.
TREATMENT PARADIGM
Modification of Environment:
Admission to a dedicated stroke unit: Patients with hemorrhagic stroke should be admitted to a specialized stroke unit to receive appropriate monitoring and management.
Administration of Pharmaceutical Agents:
Blood pressure management: Medications may be administered to lower and stabilize blood pressure within an appropriate range.
Anti-seizure medications: Prophylactic use of anti-seizure medications may be considered, especially in cases of intracerebral hemorrhage.
Hemostatic therapy: In specific cases, such as when there is a coagulopathy or anticoagulant-related bleeding, reversal agents or other hemostatic agents may be administered to control bleeding.
Intervention with Procedures:
Surgical intervention: In some instances, neurosurgical procedures may be required to evacuate the hematoma, relieve the mass effect on the brain, or repair an underlying vascular abnormality.
Endovascular procedures: Minimally invasive techniques, such as coiling or embolization, may be employed to treat certain types of hemorrhagic strokes caused by vascular abnormalities.
Phases of Management:
Acute phase: In the acute phase, the primary focus is stabilizing the patient, managing the airway, breathing, and circulation, and conducting neurologic assessments.
Subacute phase: After stabilizing the patient’s condition, further diagnostic evaluations and treatment planning are carried out.
Recovery and rehabilitation phase: As the patient progresses, rehabilitation becomes an essential management aspect.
Hemorrhagic stroke.ncbi.nlm.nih
medtigo
Hemorrhagic stroke
Updated :
August 30, 2023
Hemorrhagic stroke occurs when a blood artery ruptures and causes bleeding into the brain. Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are the primary kinds of hemorrhagic strokes.
Intracerebral Hemorrhage (ICH): This type of hemorrhagic stroke happens when a blood vessel ruptures and bleeds into the brain tissue. The bleeding causes damage to the surrounding brain cells, and the accumulation of blood creates pressure on the brain, leading to further injury.
Subarachnoid Hemorrhage (SAH): The subarachnoid space, or the gap between the brain and the delicate tissues covering it, is where SAH arises when bleeding occurs. An aneurysm rupture, a weakened area in a blood vessel wall, causes most cases of SAH. The sudden release of blood into the subarachnoid space can cause severe headaches, neck stiffness, and neurological symptoms.
10% to 20% of all strokes occur annually due to hemorrhagic stroke. Hemorrhage occurs in 8-15% of stroke cases in the United States, UK, and Australia; however, in Japan and Korea, that number rises to 18-24%. The incidence ranges from 12% to 15% per 100,000 people annually. The prevalence rises with age and is more prevalent in males.
The prevalence is rising worldwide, mostly in Asian and African nations. According to Japanese research, ICH is less common when hypertension is under control. In high-income countries, the case fatality rate ranges from 25% to 30%, whereas it ranges from 30% to 48% in low- and middle-income nations.
The primary pathophysiological processes include:
Vascular Injury: Hemorrhagic stroke can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, arteriovenous malformations, and blood clotting disorders.
Bleeding and Hematoma Formation: The hematoma can enlarge within a few hours to 12 hours after the initial bleed. Perihematomal edema, the swelling around the hematoma, increases within 24 hours, peaks around five to six days, and can persist for up to 14 days.
Mass Effect and Increased Intracerebral Pressure (ICP): The presence of hematoma causes compression of the brain tissue and increases the ICP.
Excitotoxicity and Neurotransmitter Imbalance: The disruption of neuronal function can lead to an imbalance of neurotransmitters, such as glutamate. Excessive release of glutamate and impaired clearance can result in excitotoxicity, causing further damage to neurons.
Inflammation and Secondary Injury: Hemorrhagic stroke triggers an inflammatory response in the brain. Inflammatory cells, such as microglia, are activated, releasing pro-inflammatory mediators. This inflammatory cascade can contribute to secondary injury, including damage to the blood-brain barrier.
Cerebral Ischemia and Hypoperfusion: Hemorrhagic stroke can also lead to decreased blood flow and ischemia in the surrounding brain tissue.
The primary causes of hemorrhagic stroke include:
Hypertension (High Blood Pressure): Blood vessel walls become more susceptible to perforation and hemorrhage because of prolonged hypertension.
Cerebral Amyloid Angiopathy (CAA): CAA is a condition characterized by the accumulation of amyloid protein in the walls of blood vessels in the brain.
Tumors and subarachnoid hemorrhage: Certain tumors, including glioblastoma, metastasis, lymphoma, meningioma, pituitary adenoma, and hemangioblastoma, are more prone to bleeding and can cause intracerebral hemorrhage.
Poor prognostic factors in Intracerebral hemorrhage: Several variables, such as unconsciousness at the time of presentation, an extensive hematoma with a volume larger than 30 ml, posterior fossa hemorrhage, elderly age (>80 years), high blood sugar, and chronic renal disease, suggest a poor prognosis in ICH.
Stroke unit care: The American Stroke Association (ASA) advises that individuals with intracerebral hemorrhage must be monitored and managed in a special stroke unit. It has been shown that specialized stroke units enhance results and lower death.
Functional outcomes: Only around 20% of intracerebral hemorrhage patients gain independence at six months. In cases of severe hemisphere damage or brainstem involvement, survivors may experience locked-in syndrome or a permanent vegetative state.
Intracerebral hemorrhage score: The intracerebral hemorrhage score, found by Hemphill et al., is a predictive tool for estimating mortality in ICH. It assigns points based on various factors:
Glasgow Coma Scale (GCS) score: GCS 3 to 4 get two points, GCS 5 to 12 gets one point, and GCS 13 to 15 gets none.
Age: one point for those over 80, zero points for people under 80.
one point for an infratentorial (posterior fossa) hemorrhage, zero points for a supratentorial hemorrhage.
The projected thirty-day mortality risk is based on the overall score. The death rates are as follows: 100% for scores 5 and 6, 97% for scores 4, 72% for scores 3, 26% for scores 2, 13% for scores 1 and 2,and 0% for scores 0 and 1
CLINICAL HISTORY
Age group: The clinical presentation of hemorrhagic stroke may differ among different age groups.
Younger adults: Hemorrhagic stroke in younger adults may be associated with underlying conditions such as vascular malformations, drug abuse (e.g., cocaine), or specific genetic disorders.
Older adults: Hemorrhagic stroke is more prevalent in older adults, particularly those over 55.
The critical components of the physical examination:
Vital signs: Assessing vital signs provides crucial information about the patient’s overall condition and helps monitor any signs of instability.
Blood pressure: High blood pressure is a common risk factor for hemorrhagic stroke, so measuring blood pressure is essential.
Heart rate and rhythm: Irregularities or abnormalities in heart rate and rhythm may indicate underlying cardiovascular conditions.
Neurological examination: Evaluating the patient’s neurological function is vital to identify any focal deficits or signs of increased intracerebral pressure.
Mental status: Assessing the patient’s level of consciousness, orientation, and cognitive function.
Cranial nerves: Testing the function of various cranial nerves, including visual acuity, pupillary responses, facial movements, and eye movements.
Motor function: Assessing muscle strength, tone, and coordination in all extremities.
Cardiovascular examination: Evaluating the cardiovascular system helps identify underlying conditions or complications.
Auscultation of the heart: Listening for abnormal heart sounds, murmurs, or irregular rhythms.
Peripheral pulses: Assessing the strength and regularity of pulses in the extremities.
Respiratory examination: Assessing the patient’s respiratory function helps monitor oxygenation and identify respiratory complications.
Respiratory rate: Counting the patient’s breaths per minute.
Auscultation of the lungs: Listening for abnormal breath sounds, such as crackles or diminished breath sounds.
Associated comorbidity or activity:
Comorbidities or engagement in certain activities can impact the clinical presentation of hemorrhagic stroke.
Hypertension: Uncontrolled hypertension can lead to vessel wall damage and increase the risk of bleeding in the brain.
Coagulopathy: Conditions that affect the blood’s ability to clot, such as hemophilia, liver disease, or anticoagulant medications, can increase the risk of hemorrhagic stroke.
Trauma: Traumatic brain injury (TBI) can result in intracerebral bleeding, leading to stroke symptoms.
Acuity of presentation:
Sudden onset: Hemorrhagic stroke often presents with a sudden onset of symptoms. Patients may describe the sudden onset of severe headache, accompanied by neurological deficits such as weakness, numbness, difficulty speaking, or loss of consciousness.
Rapid progression: The symptoms of hemorrhagic stroke can rapidly progress within minutes to hours after the onset.
Thunderclap headache: A thunderclap headache, a severe and sudden-onset headache, can be a characteristic feature of hemorrhagic stroke.
DIFFERENTIAL DIAGNOSIS
The differential diagnoses of hemorrhagic stroke are as follows:
Acute hypertensive crisis: Uncontrolled high blood pressure can lead to bleeding in the brain and present with symptoms like hemorrhagic stroke.
Pituitary apoplexy: This condition occurs when there is bleeding in the pituitary gland, typically associated with an underlying pituitary tumor.
Cerebral venous thrombosis: It is the formation of a blood clot in the cerebral veins, impeding blood drainage from the brain.
Dural sinus thrombosis: Dural sinuses are large veins that drain blood from the brain. Thrombosis or blockage of these sinuses can lead to symptoms resembling hemorrhagic strokes.
Cervical artery dissection: Dissection of the carotid or vertebral arteries can cause bleeding and present with symptoms like stroke.
Reversible cerebral vasoconstrictive syndrome (RCVS): RCVS is characterized by sudden constriction and narrowing of the brain’s blood vessels, leading to headaches, neurological symptoms, and, in some cases, bleeding.
Hemorrhagic neoplasms: Certain tumors, such as brain tumors or metastatic lesions, can cause bleeding and present with symptoms resembling hemorrhagic stroke.
TREATMENT PARADIGM
Modification of Environment:
Admission to a dedicated stroke unit: Patients with hemorrhagic stroke should be admitted to a specialized stroke unit to receive appropriate monitoring and management.
Administration of Pharmaceutical Agents:
Blood pressure management: Medications may be administered to lower and stabilize blood pressure within an appropriate range.
Anti-seizure medications: Prophylactic use of anti-seizure medications may be considered, especially in cases of intracerebral hemorrhage.
Hemostatic therapy: In specific cases, such as when there is a coagulopathy or anticoagulant-related bleeding, reversal agents or other hemostatic agents may be administered to control bleeding.
Intervention with Procedures:
Surgical intervention: In some instances, neurosurgical procedures may be required to evacuate the hematoma, relieve the mass effect on the brain, or repair an underlying vascular abnormality.
Endovascular procedures: Minimally invasive techniques, such as coiling or embolization, may be employed to treat certain types of hemorrhagic strokes caused by vascular abnormalities.
Phases of Management:
Acute phase: In the acute phase, the primary focus is stabilizing the patient, managing the airway, breathing, and circulation, and conducting neurologic assessments.
Subacute phase: After stabilizing the patient’s condition, further diagnostic evaluations and treatment planning are carried out.
Recovery and rehabilitation phase: As the patient progresses, rehabilitation becomes an essential management aspect.
Hemorrhagic stroke.ncbi.nlm.nih
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