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hemorrhagic stroke

A stroke resulting from the rupture of a blood vessel in the brain. Etiology: 1) see more specific type a) intracerebral hemorrhage b) cerebellar hemorrhage c) brainstem hemorrhage d) subarachnoid hemorrhage 2) risk factors - women with LDL cholesterol < 70 mg/dL with 2-fold increased risk relative to women with LDL cholesterol 100-130 mg/dL [12] - see risk factors associated with ischemic stroke Epidemiology: 20-25% of strokes Clinical manifestations: - hemiparesis less common than in ischemic stroke - meningeal signs may be present - seizures - signs of increased intracranial pressure - nausea, vomiting - headache - loss of consciousness [10] Laboratory: - CSF analysis for xanthochromia Special laboratory: - lumbar puncture & CSF analysis is indicated for any patient with sudden severe headache & normal findings on head CT - electrocardiogram - atrial fibrillation would suggest embolic stroke [10] Radiology: - head CT faster & less expensive than MRI of head Complications: 1) antiplatelet therapy associated with higher mortality [3] 2) seizures early after stroke a) more common with hemorrhagic stroke than ischemic stroke (15% vs 4%) [4] b) more common with cortical stroke than subcortical stroke (19% vs 10%) c) do not predict mortality or function at 6 months [4] 3) intracerebral hematoma growth associated with poor outcomes [5] 4) risk of pneumonia is highest in the 1st week after stroke [13] 5) hypertension after intracerebral hemorrhage - more common in blacks that whites (63% vs 38%) Management: 1) see general measures under stroke (CVA) 2) see more specific measures under a) intraparenchymal hemorrhagic stroke b) subarachnoid hemorrhage 3) systolic blood pressure control a) target systolic blood pressure 140-160 mm Hg [5,9] or mean arterial pressure = 110 mm Hg [7] b) assumption is that excessively high systolic blood pressure will increase hematoma size [9] c) preferred antihypertensive agents - nicardipine - labetolol 4) control bleeding a) use of anticoagulants & antiplatelet agents within 1st 48 hour contraindicated b) LMW heparin can be started 48 hours after hemorrhagic stroke [7] - prophylaxis for venous thromboembolism in bedridden patients - 2 post-stroke head CTs 48 hours apart without evidence of bleed clears patient for LMW heparin [7] c) maintain platelet count of >= 100,000/uL [7,8] 5) intracranial pressure monitor mentioned [7] 6) see Surgical Trial In Intracerebral Hemorrhage 7) neurorehabilitation 8) factor VIIa NOT useful [1] 9) apparently, low dose aspirin may be continued after 48 hours [11] - this recommendation differs from hemorrhagic transformation of ischemic stroke when aspirin should be 2-7 days [7] 10) anticonvulsants not indicated in absence of seizure or epileptiform activity on EEG [11]

Related

Surgical Trial In Intracerebral Hemorrhage (STICH)

Specific

acute hemorrhagic leukoencephalopathy brainstem hemorrhage cerebellar hemorrhage intracerebral hemorrhage (ICH) subarachnoid hemorrhage (SAH)

General

stroke; cerebrovascular accident (CVA) cerebrovascular hemorrhage

References

  1. Mayer SA et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2008 May 15; 358:2127. PMID: 18480205
  2. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M; American Heart Association; American Stroke Association Stroke Council; High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun;38(6):2001-23. Epub 2007 May 3. PMID: 17478736 http://stroke.ahajournals.org/content/vol38/issue6/#AHA_ASA_GUIDELINE
  3. Thompson BB et al. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: A systematic review. Neurology 2010 Oct 12; 75:1333 PMID: 20826714
  4. Beghi E et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology 2011 Nov 15; 77:1785 PMID: 21975208 - De Herdt V et al. Early seizures in intracerebral hemorrhage: Incidence, associated factors, and outcome. Neurology 2011 Nov 15; 77:1794. PMID: 21975203
  5. Delcourt C et al. Hematoma growth and outcomes in intracerebral hemorrhage: The INTERACT1 study. Neurology 2012 Jul 24; 79:314. PMID: 22744655
  6. Zahuranec DB et al Poor Long-Term Blood Pressure Control After Intracerebral Hemorrhage Stroke August 16, 2012 PMID: 22903494 http://stroke.ahajournals.org/content/early/2012/08/16/STROKEAHA.112.663047.abstract
  7. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  8. Slichter SJ. Evidence-based platelet transfusion guidelines. Hematology Am Soc Hematol Educ Program. 2007:172-8. PMID: 18024626
  9. Morgenstern LB, Hemphill JC 3rd, Anderson C et al Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep;41(9):2108-29 PMID: 20651276
  10. The NNT: Hemorrhagic Stroke Diagnostics and Likelihood Ratios, Explained http://www.thennt.com/lr/hemorrhagic-stroke/ - Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010 Jun 9;303(22):2280-6. PMID: 20530782
  11. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  12. Yasgur BS Low Cholesterol Linked to Higher Hemorrhagic Stroke Risk. Medscape - Apr 15, 2019
  13. Parr E, Ferdinand P, Roffe C. Management of Acute Stroke in the Older Person. Geriatrics (Basel). 2017 Aug 15;2(3):27. doi: 10.3390/geriatrics2030027. PMID: 31011037 PMCID: PMC6371128 Free PMC article.