>> Now to go over hemorrhagic strokes.
The objectives of this presentation
is that you will be able to list
the two types of hemorrhagic strokes,
list the signs and symptoms,
and three concerns for patients experiencing
a hemorrhagic stroke.
Hemorrhagic strokes account
for about 15 to 20% of all strokes.
And when a patient has a hemorrhagic stroke,
this is due to a rupture of a weakened blood vessel
that bleeds into the brain tissue.
But depending on where that blood vessel is that leaks,
that will tell us which type of hemorrhagic stroke we have.
So the first type we have
is a subarachnoid hemorrhage or an SH.
This accounts for 41% of strokes.
When we think of subarachnoid,
we think of the subarachnoid space,
and this is part of your meninges around your brain.
When you have bleeding into this space,
is primarily the result of cerebral aneurysm or trauma.
Something to note is that patient
that has a subarachnoid hemorrhage due to a trauma
is not considered part of our stroke program.
If a patient has a subarachnoid hemorrhage
that is due to a vascular issue or weakness,
then it is included in our stroke program.
For intracerebral hemorrhages,
this accounts for a larger percentage
of our hemorrhagic strokes, that's 60%,
and to be included in our stroke program,
it has to be a spontaneous non-traumatic bleeding directly
into the brain tissue or the brain prank them up.
When it comes to hemorrhagic strokes,
there are higher rates of morbidity
and mortality compared to ischemic strokes.
As far as risk factors for hemorrhagic stroke,
ones within your control include hypertension,
which once again is the number one risk factor,
as same as ischemic stroke.
As well, we have smoking, excess of alcohol intake,
liver and kidney disease, drug abuse, brain tumors,
bleeding disorders, and blood vessel abnormalities,
which could include aneurysms,
arterial venous malformations, patients who have vasculitis
and amyloid angiopathy or (mumbles) disease.
Outside of your control risk factors include age and gender.
As far as age, the incidence increases after the age of 45.
And for gender more men compared to women have a stroke,
have an hemorrhagic stroke, sorry.
As far as the signs and symptoms,
you might have a lot of the similar signs and symptoms
of an ischemic stroke,
but these are some additional ones you might see.
So you still might have cranial nerve deficits.
We might see a facial droop and other focal deficits,
but the patient may experience a sudden severe headache,
this worst headache of their life.
And then they sometimes call it the Thunderclap headache.
As well, patients may experience nausea and vomiting.
They might have a loss of consciousness, onset of confusion,
weakness on one side, vision changes,
might have photophobia, difficulty speaking
or understanding speech, stiff neck or neck pain
and your patient may experience a seizure prior to having,
coming in and being identified
as having a hemorrhagic stroke.
As far as the diagnosis of hemorrhagic stroke,
we first, because the patient comes in,
if they're looking like they're having a stroke,
we're gonna get a dry non-contrast CT.
And here where we can see here on the picture to the right,
the white area of where we have a bleed.
Patients might also get a CTA
or other types of angiography like MRI angiography,
or cerebral angiography.
And this just helps get a better picture of the vasculature
to see what the source of the bleed is from.
Patients as well might get a lumbar puncture
cause sometimes these bleeds can actually
also go into the ventricles and we might need
to see if there is blood in the ventricles.
If we're sort of unsure on the scans.
With regards to subarachnoid hemorrhages,
this accounts for about 5% of all strokes,
and this is where we have blood vessels outside of the brain
that ruptured causing blood
to fill in the subarachnoid space.
It is frequently caused by abnormalities of the arteries
at the base of the brain, especially our cerebral aneurysms
and this accounts for about 85%.
As well might be caused from arteriovenous malformations
and trauma, as I said, trauma is not included as something
that we can necessarily prevent as part of a stroke.
Subarachnoid hamburgers also can extend to the ventricles
if a subarachnoid hemorrhage spreads to the ventricles,
it is associated with a poor outcome for patients.
So there's the picture.
Here we can see the subarachnoid space
and that middle layer of the meninges.
As far as aneurysmal subarachnoid hemorrhage epidemiology,
there's about 28,000 aneurysmal subarachnoid hemorrhages
per year in the United States.
And actually an autopsy studies, patients,
people who are non-symptomatic of having an aneurysmal bleed
actually 5% of the general population will find that
they have an aneurysm in autopsy studies.
Aneurysmal subarachnoid hemorrhages affects more women
than men with a three to two ratio
with mean age onset of 30 to 60 years.
10 to 15% of patients that have
an SAH die before reaching the hospital.
And about 50% of survivors have major disability.
As far as risk factors for subarachnoid hemorrhage,
once again hypertension is the number one risk factor.
Other ones include cigarette smoking, oral contraceptives,
pregnancy or the patrician period,
a history of cocaine abuse as you're increasing with age
and any of these types
of inherited connective tissue disorders.
We have some surgical treatment options for aneurysms.
So we can do a surgical clipping.
This is where we actually have to do a craniotomy
and go through the tissue to actually clip, put a clip.
As we can see here in the picture to the right,
and this will be on the neck of this berry aneurysm,
and then another option is endovascular coiling or stenting.
And it could be both with the coiling,
we have a microcatheter that gets threaded
to the aneurysm through an artery.
They'll fill the aneurysm with coils, they'll heat them up,
and this will help to obstruct the flow to the brain.
And as I said, you might also have a stent with the coiling.
So you have the coiling go in and then they put a stent
in place to have the blood flow be diverted
so it doesn't go into
that weakened outpouching of the vasculature.
With intracerebral hemorrhages.
This is where we have bleeding within the brain tissue
or the brain parenchyma.
And we see this most frequently in our cerebral lobes,
the basal ganglia, the thalamus, pons, the cerebellum,
and it can't extend also to the ventricles in the brain.
It is common to have bleeding in the cerebral lobes,
from the arteries of the anterior middle
and posterior cerebral arteries.
As far as the prevalence of ICH is,
it occurs in about 40 to 50,000 persons in the U.S. a year.
There's an up to 50% mortality study within a month
and an up to 50% disability at a year.
There is an increased incidence in ICH is among males.
When your age is greater than 55
and those of black and Japanese ethnicity.
Common causes of ICH include hypertension,
arterialvenous malformations and once again,
trauma to the head.
When patients have bleeds, main concerns with the patients
who's had hemorrhagic stroke are mainly these few things.
So first off we can say, we're concerned with vasospasms.
And this is where we have delayed cerebral ischemia.
When you think of spasms, you can think of the vascular sort
of clamping down and opening, so it clamps down and opens.
And what happens is if you see on the picture to the right,
where the picture B further to the right,
you can see nice big open vasculature,
but then in the picture to the left in A,
you can see the same sort of in the middle.
It has collapsed and it's really small.
What happens is this is sort of like having constriction
and dilation happening is that you can actually
cause a patient that has a hemorrhagic stroke
to actually have an ischemic stroke as well
cause you're causing ischemia
with the clamping down of the vasculature.
These assess spasms usually onset within a by day,
around day 4 to 14 after a bleed.
And it peaks after subarachnoid hemorrhage
around days six to eight, but patients remain at risk
for up to 21 days.
When a patient has had a subarachnoid hemorrhage,
we frequently have transcranial doppler done daily
to see if a patient is having vasospasms.
To make sure that we're treating the basal spasms,
usually giving patients extra fluid to maintain
the amount of fluid in the vasculature.
We're also concerned for patient's re bleeding.
So patient, if they have blood in their brain,
it may just form a clot and end there,
but we're worried if the bleed increases
and if it increases, this is the point that we can have
the blood starts acting like a mass occupying lesion,
and we have what's called mass effect.
So we'll start, we could start seeing
some compression on the brainstem.
Remember the brainstem is where you're controlling
your breathing and your pulse.
In these patients are at much higher risk
where they need to be intubated.
And then as well, when you have brain tissue being pushed
to the side because of blood there,
you're risking your patients having
any of a numerous types of herniation syndromes.
Also when there's blood in the brain,
the blood that's there, it causes tissue damage
and can cause some cerebral edema.
And there's also some neurotoxic release.
So even the healthy brain that is around the blood,
that can be irritated also from the blood
and we can have damage to the tissue from that.
As well when we have a subarachnoid hemorrhage
or an ICH that goes into the ventricles,
if we have blood that collects there and it prevents
the CSF from flowing down through your ventricles
and then around to your spinal cord and around your brain,
we can then deal with patients
having obstructive hydrocephalus,
which has major concern for patients
when they've had bleeds.
Next up, we'll do a review
of The National Institute Of Health Stroke Scale,
and also do go over nursing care of a stroke patient.