Hemorrhagic stroke - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Weakness of upper and lower limbs pattern of weakness depend on the place of involvement. When anterior cerebral artery is involved contralateral side weakness of the upper and lower limbs occur, but lower limbs weakness is more than upper limbs. When middle cerebral artery is involved weakness of the lower limbs and upper limbs occur, but upper limbs weakness is more than lower. ,,, Weakness of upper and lower limbs
pattern of weakness depend on the place of involvement. When anterior cerebral artery is involved contralateral side weakness of the upper and lower limbs occur, but lower limbs weakness is more than upper limbs. When middle cerebral artery is involved weakness of the lower limbs and upper limbs occur, but upper limbs weakness is more than lower. ,,,
speech Dysarthria occurs when hemorrhage occurs in posterior inferior carebral artery. when middle cerebral artery is involved dysphasia(dominant hemisphere) or apraxia( non -dominant hemisphere) can occur.,,, speech
Dysarthria occurs when hemorrhage occurs in posterior inferior carebral artery. when middle cerebral artery is involved dysphasia(dominant hemisphere) or apraxia( non -dominant hemisphere) can occur.,,,
behavior abnormalities when anterior circulation is involved higher function get altered.,,, behavior abnormalities
when anterior circulation is involved higher function get altered.,,,
memory impairment when anterior circulation is involved higher function get altered.,,, memory impairment
when anterior circulation is involved higher function get altered.,,,
Dysphagia occurs when hemorrhage occurs in posterior inferior carebral artery.,,, Dysphagia
occurs when hemorrhage occurs in posterior inferior carebral artery.,,,
seizures In 4-28% of patients early seizure activity occurs with intracerebral hemorrhage ,,, seizures
In 4-28% of patients early seizure activity occurs with intracerebral hemorrhage ,,,
Visual symptoms Patent may have visual disturbance according to the site of the hemorrhage. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery. ,,, Visual symptoms
Patent may have visual disturbance according to the site of the hemorrhage. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery. ,,,
onset of symptoms vascular pathologies have an acute onset of symptoms. ,,, onset of symptoms
vascular pathologies have an acute onset of symptoms. ,,,
alcohol intake heavy alcohol consumption of >5 units/day increase the risk by 1.6. ,,, alcohol intake
heavy alcohol consumption of >5 units/day increase the risk by 1.6. ,,,
Smoking habits smoking increase the risk by 1.6. Smoking reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. ,,, Smoking habits
smoking increase the risk by 1.6. Smoking reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. ,,,
history of cardiovascular diseases hypertension, dyslipidaemia, diabetes and myocardial infartion increase the risk of hemorrhage.,,, history of cardiovascular diseases
hypertension, dyslipidaemia, diabetes and myocardial infartion increase the risk of hemorrhage.,,,
History of bleeding disorders patient with bleeding disorders can get cerebral hemorrhage. ,,, History of bleeding disorders
patient with bleeding disorders can get cerebral hemorrhage. ,,,
History of recent trauma patient with a history of recent trauma can have undiagnosed cerebral hemorrhage , which can cause acute stroke. ,,, History of recent trauma
patient with a history of recent trauma can have undiagnosed cerebral hemorrhage , which can cause acute stroke. ,,,
Drug history oral contraceptive use is important as they can cause disorders coagulation.
Warfarin has an increased incidence of hemorrhagic stroke. Morbidity and mortality of this is high, with over 50% dying within 30 days. ,,,
Drug history
oral contraceptive use is important as they can cause disorders coagulation.
Warfarin has an increased incidence of hemorrhagic stroke. Morbidity and mortality of this is high, with over 50% dying within 30 days. ,,,
use of cocaine Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre‐synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine‐induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation. use of cocaine
Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre‐synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine‐induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation.
Family history Intracranial aneurysms may result from genetic disorders. Some families may have a predisposition, which is inherited in an autosomal dominant manner for intracranial berry aneurysms. Aneurysms are also seen with Autosomal dominant polycystic kidney disease (ADPKD) ,,, Family history
Intracranial aneurysms may result from genetic disorders. Some families may have a predisposition, which is inherited in an autosomal dominant manner for intracranial berry aneurysms. Aneurysms are also seen with Autosomal dominant polycystic kidney disease (ADPKD) ,,,

Clinicals - Examination

Fact Explanation
ABC - Airway, breathing and circulation As this is an emergency patients' airway, breathing and circulation has to assessed first. If there is a impairment in any of them immediate resuscitation has to be carried out. ABC - Airway, breathing and circulation
As this is an emergency patients' airway, breathing and circulation has to assessed first. If there is a impairment in any of them immediate resuscitation has to be carried out.
Level of consciousness according to the National Institutes of Health Stroke Scale (NIHSS) level of consciousness is assessed using alertness, ability to answer questions regarding the month and his/her age and the ability in eye opening, gripping and releasing the non-paretic hand. Level of consciousness
according to the National Institutes of Health Stroke Scale (NIHSS) level of consciousness is assessed using alertness, ability to answer questions regarding the month and his/her age and the ability in eye opening, gripping and releasing the non-paretic hand.
Cranial Nerves This helps to localize the hemorrhage. Seen in Vertebrobasilar artery involvement. Cranial Nerves
This helps to localize the hemorrhage. Seen in Vertebrobasilar artery involvement.
Cerebellar Signs and Gait This helps to localize the hemorrhage. Seen in Vertebrobasilar artery involvement.. Gait apraxia can be seen in anterior cerebral artery involvement. Cerebellar Signs and Gait
This helps to localize the hemorrhage. Seen in Vertebrobasilar artery involvement.. Gait apraxia can be seen in anterior cerebral artery involvement.
Neurological examination of limbs - motor & reflexes when assessing the motor function of the upper and lower limbs weakness is shown according to the place of hemorrhage. This helps in localizing the hemorrhage. ,,, Neurological examination of limbs - motor & reflexes
when assessing the motor function of the upper and lower limbs weakness is shown according to the place of hemorrhage. This helps in localizing the hemorrhage. ,,,
Neurological examination of limbs - sensory when assessing the sensory function of the upper and lower limbs sensory loss is shown according to the place of hemorrhage. This helps in localizing the occlusion. When infarct occur in lacunar circulation pure sensory stroke can occur without any motor weakness,,, Neurological examination of limbs - sensory
when assessing the sensory function of the upper and lower limbs sensory loss is shown according to the place of hemorrhage. This helps in localizing the occlusion. When infarct occur in lacunar circulation pure sensory stroke can occur without any motor weakness,,,
eye examination visual disturbance also differ with the site of the hemorrhage. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery.,,, eye examination
visual disturbance also differ with the site of the hemorrhage. If occur in opthalmic artery loss of vision in that eye occur, hemianopia occur in middle cerebral artery or posterior cerebral artery.,,,
Cardiovascular examination pulse examination is important in identifying arrhythmias. As strokes may occur concurrently with other acute cardiac conditions as acute myocardial infarction and acute heart failure, auscultation for murmurs and gallops is recommended. ,,, Cardiovascular examination
pulse examination is important in identifying arrhythmias. As strokes may occur concurrently with other acute cardiac conditions as acute myocardial infarction and acute heart failure, auscultation for murmurs and gallops is recommended. ,,,

Investigations - Diagnosis

Fact Explanation
Non contrast CT Done to identify hemorrhagic stroke. Widely used because it is better tolerated and easier to perform than MRI. ,,, Non contrast CT
Done to identify hemorrhagic stroke. Widely used because it is better tolerated and easier to perform than MRI. ,,,
MRI With its newest sequence DWI (diffusion - weighted imaging) has a great sensitivity than CT to differentiate hemorrhage from a infarct. Not widely used because it is slow and difficult to scan unstable, critically ill patient. ,,, MRI
With its newest sequence DWI (diffusion - weighted imaging) has a great sensitivity than CT to differentiate hemorrhage from a infarct. Not widely used because it is slow and difficult to scan unstable, critically ill patient. ,,,
ECG Done to evaluate conduction defect in heart as arrhythmia can cause emboli that can lead to cerebral infarction. ,,, ECG
Done to evaluate conduction defect in heart as arrhythmia can cause emboli that can lead to cerebral infarction. ,,,

Investigations - Management

Fact Explanation
Coagulation profile done to evaluate coagulation of the patient and to identify any risk of coagulopathy.,, Coagulation profile
done to evaluate coagulation of the patient and to identify any risk of coagulopathy.,,
Lipid profile Done to evaluate the dyslipidemia. This is important to modify the management accordingly.,, Lipid profile
Done to evaluate the dyslipidemia. This is important to modify the management accordingly.,,
Glucose level Done to evaluate the diabetic control of the patient.,, Glucose level
Done to evaluate the diabetic control of the patient.,,
ECG done to evaluate the cardiac function.,, ECG
done to evaluate the cardiac function.,,
ECG Done to evaluate the cardiac function of the patient. infaction, conduction defects are identified. ,, ECG
Done to evaluate the cardiac function of the patient. infaction, conduction defects are identified. ,,
FBC This is done to identify any infections or anemia. this is important in planning management.,, FBC
This is done to identify any infections or anemia. this is important in planning management.,,
Coagulation Profile done to identify coagulopathy ,, Coagulation Profile
done to identify coagulopathy ,,
lipid profile Done to evaluate the dyslipidemia. As dyslipidemia is a risk factor for infarction it is important to identify undiagnosed dyslipidemia. ,, lipid profile
Done to evaluate the dyslipidemia. As dyslipidemia is a risk factor for infarction it is important to identify undiagnosed dyslipidemia. ,,
fasting glucose done to identify undiagnosed diabetes or evaluate the current diabetes status.,, fasting glucose
done to identify undiagnosed diabetes or evaluate the current diabetes status.,,
Renal function test Done to evaluate the renal function. Important in planing the management. ,, Renal function test
Done to evaluate the renal function. Important in planing the management. ,,
Toxicology Screen Urine toxicology studies done to identify cocaine,, Toxicology Screen
Urine toxicology studies done to identify cocaine,,
Cardiac biomarkers Done to evaluate the cardiac function of the patient and to possibility of myocardial infarction. ,, Cardiac biomarkers
Done to evaluate the cardiac function of the patient and to possibility of myocardial infarction. ,,
Ultrasound scan of the kidney done to look for polycystic kidneys, as berry aneurysms are common in polycystic kidneys.,, Ultrasound scan of the kidney
done to look for polycystic kidneys, as berry aneurysms are common in polycystic kidneys.,,
NIH Stroke Score This is a systematic clinical assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Consist of a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral hemorrhage on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. A score >10 suggests 80% likelihood of involvement of proximal vessels NIH Stroke Score
This is a systematic clinical assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Consist of a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral hemorrhage on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. A score >10 suggests 80% likelihood of involvement of proximal vessels

Management - Supportive

Fact Explanation
stop smoking Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but effective treatments and helpful resources exist. stop smoking
Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but effective treatments and helpful resources exist.
physical activities Activity limitations are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. physical activities
Activity limitations are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training.
diet Healthy diet should be taken with low fats, sugar and salt; and rich in fruits and vegetables. if patient is having difficulty in chewing or swallowing diet has to be changed accordingly. diet
Healthy diet should be taken with low fats, sugar and salt; and rich in fruits and vegetables. if patient is having difficulty in chewing or swallowing diet has to be changed accordingly.
Rehabilitation The rehabilitation process involves six major areas of focus; preventing, recognizing, and managing comorbid illness and medical complications; training for maximum independence; facilitating maximum psychosocial coping and adaptation by patient and family; preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; enhancing quality of life in view of residual disability; and preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke. To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence. Rehabilitation
The rehabilitation process involves six major areas of focus; preventing, recognizing, and managing comorbid illness and medical complications; training for maximum independence; facilitating maximum psychosocial coping and adaptation by patient and family; preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; enhancing quality of life in view of residual disability; and preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke. To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence.
Patient education As the patient may have long term disabilities, patient and family have to be educated regarding that and about the risk factors of stroke in order to prevent it among relatives. Patient education
As the patient may have long term disabilities, patient and family have to be educated regarding that and about the risk factors of stroke in order to prevent it among relatives.
Palliative Care Primary palliative care should begin at the diagnosis. This includes patients for whom some reversibility is a realistic goal but for whom the stroke itself or its treatments pose significant burdens and may result in reduced quality of life. Palliative care should also be available to those stroke patients with significant functional impairments who have progressive chronic comorbidities, who are unlikely to recover, and for whom intensive palliative care is the predominant focus and goal for the remainder of their lives. Palliative Care
Primary palliative care should begin at the diagnosis. This includes patients for whom some reversibility is a realistic goal but for whom the stroke itself or its treatments pose significant burdens and may result in reduced quality of life. Palliative care should also be available to those stroke patients with significant functional impairments who have progressive chronic comorbidities, who are unlikely to recover, and for whom intensive palliative care is the predominant focus and goal for the remainder of their lives.

Management - Specific

Fact Explanation
acute management Assess the patient's air way, breathing, circulation and resuscitation has to be done first. Special attention should be given to detecting signs of external trauma. ,, acute management
Assess the patient's air way, breathing, circulation and resuscitation has to be done first. Special attention should be given to detecting signs of external trauma. ,,
Hypertention management Antihypertensive therapy is effective in reducing the risk of recurrent stroke. Careful identification of hypertensive patients with stroke and TIA, with initiation of single or combination therapy, is essential for secondary stroke prevention. ,, Hypertention management
Antihypertensive therapy is effective in reducing the risk of recurrent stroke. Careful identification of hypertensive patients with stroke and TIA, with initiation of single or combination therapy, is essential for secondary stroke prevention. ,,
Seizure control Patients with clinical seizures or EEG seizure activity accompanied with change in mental status are treated with antiepileptic drugs.
Benzodiazepine, such as lorazepam or diazepam, are given immediately for rapid seizure control followed by phenytoin or fosphenytoin for longer-term control.
Primary prophylaxis is not indicated for poststroke seizures while standard antiepileptic therapy is recommended for secondary prevention of subsequent seizures . ,,
Seizure control
Patients with clinical seizures or EEG seizure activity accompanied with change in mental status are treated with antiepileptic drugs.
Benzodiazepine, such as lorazepam or diazepam, are given immediately for rapid seizure control followed by phenytoin or fosphenytoin for longer-term control.
Primary prophylaxis is not indicated for poststroke seizures while standard antiepileptic therapy is recommended for secondary prevention of subsequent seizures . ,,
Intracranial Pressure Control In emergency situations, mannitol and other therapies may be used to reduce intracranial pressure (ICP). However, prompt neurosurgical assistance should be sought when indicated.

Patient positioning, hyperosmolar therapy, hyperventilation, and, barbiturate coma may also be considered where appropriate.

In patients with large hemispheric infarctions associated with life-threatening edema, hemicraniectomy may decrease resultant mortality and disability.,,
Intracranial Pressure Control
In emergency situations, mannitol and other therapies may be used to reduce intracranial pressure (ICP). However, prompt neurosurgical assistance should be sought when indicated.

Patient positioning, hyperosmolar therapy, hyperventilation, and, barbiturate coma may also be considered where appropriate.

In patients with large hemispheric infarctions associated with life-threatening edema, hemicraniectomy may decrease resultant mortality and disability.,,
Hemostatic Therapy Hemostatic therapy with rFVIIa is used to stop ongoing hemorrhage or prevent hematoma expansion. ,, Hemostatic Therapy
Hemostatic therapy with rFVIIa is used to stop ongoing hemorrhage or prevent hematoma expansion. ,,
Reversal of warfarin anticoagulation Should be done as quickly as possible in means of preventing further hematoma expansion. This can be done using Intravenous vitamin K, Prothrombin complex concentrates (PCC), Fresh frozen plasma (FFP) and rFVIIa ,, Reversal of warfarin anticoagulation
Should be done as quickly as possible in means of preventing further hematoma expansion. This can be done using Intravenous vitamin K, Prothrombin complex concentrates (PCC), Fresh frozen plasma (FFP) and rFVIIa ,,
surgical evacuation The decision about whether and when to operate remains controversial. Patients with small hemorrhages (<10 cm3) or minimal neurological deficits should be treated medically because they generally do well with medical treatment alone. Patients with a GCS score ≤4 should also be treated medically because they uniformly die or have extremely poor functional outcome that cannot be improved by surgery. Patients with cerebellar hemorrhage >3 cm in diameter who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible. Young patients with large lobar hemorrhages (≥50 cm3) who deteriorate during observation often undergo surgical removal of the hemorrhage. An ICH associated with a structural lesion such as an aneurysm or a vascular malformation may be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible. ,, surgical evacuation
The decision about whether and when to operate remains controversial. Patients with small hemorrhages (<10 cm3) or minimal neurological deficits should be treated medically because they generally do well with medical treatment alone. Patients with a GCS score ≤4 should also be treated medically because they uniformly die or have extremely poor functional outcome that cannot be improved by surgery. Patients with cerebellar hemorrhage >3 cm in diameter who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible. Young patients with large lobar hemorrhages (≥50 cm3) who deteriorate during observation often undergo surgical removal of the hemorrhage. An ICH associated with a structural lesion such as an aneurysm or a vascular malformation may be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible. ,,

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