Hemorrhagic stroke natural history

Jump to navigation Jump to search

Hemorrhagic stroke Microchapters

Main Stroke Page

Ischemic Stroke Page

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Stroke from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Emergency Diagnosis and Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

CT

MRI

Other Imaging Findings

Treatment

Early Assessment

NIH Stroke Scale

Management

Surgery

Rehabilitation

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015)

Management of ICH

AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

Management of aSAH

AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014)

Primary Prevention of Stroke

AHA/ASA Guideline Recommendations for Prevention of Stroke in Women (2014)

Overview

Sex-Specific Risk Factors

Pregnancy and Complications
Cerebral Venous Thrombosis
Oral Contraceptives
Menopause and Postmenopausal Hormonal Therapy

Risk Factors Commoner in Women

Migraine with Aura
Obesity, Metabolic Syndrome, and Lifestyle Factors
Atrial Fibrillation

Prevention

Case Studies

Case #1

Hemorrhagic stroke natural history On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Hemorrhagic stroke natural history

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Hemorrhagic stroke natural history

CDC on Hemorrhagic stroke natural history

Hemorrhagic stroke natural history in the news

Blogs on Hemorrhagic stroke natural history

Directions to Hospitals Treating Stroke

Risk calculators and risk factors for Hemorrhagic stroke natural history

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Natural history

In Inracerebral hemorrhage|Inracerebral hemorrhage (ICH), underlying small vessel disease may result in acute vessel rupture. This acute vessel rupture can progress can result in brain injury by folllowing mechanisms:

All of these mechnisems can lead to perihematomal edema formation and secondary brain injury. Aditionally, continued bleeding, or hematoma expansion, occurs in many patients—either continued bleeding from the primary source or secondary bleeding at the periphery of the hemorrhage


Based on the anatomic location and size of the hemorrhage, hemorrhagic stroke may have a different outcome

  • Large clot may form and compress adjacent tissue, and may result in herniation and death.
  • Blood may also dissect into the ventricular space, which substantially increases morbidity and may cause hydrocephalus


Baseline NIHSS and Glasgow Coma Scale (GCS) scores can be used to assess stroke severity, although the GCS score may be more feasible to follow for neurologic deterioration ( Box 101-3 ). In addition, serial examinations can detect early changes that may suggest ongoing bleeding during the acute phase. (NIH) Stroke Scale Scoring

National Institutes of Health Stroke Scale

The National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke. The NIHSS is composed of 11 items, each of which scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment.[1] The individual scores from each item are summed in order to calculate a patient's total NIHSS score. The maximum possible score is 42, with the minimum score being a 0.[2][3]

Score[3] Stroke severity
0
  • No stroke symptoms
1-4
  • Minor stroke
5-15
  • Moderate stroke
16-20
  • Moderate to severe stroke
21-42
  • Severe stroke

The National Institutes of Health Stroke Scale has been repeatedly validated as a tool for assessing stroke severity and as an excellent predictor for patient outcomes.[4][5][6] Severity of a stroke is heavily correlated with the volume of brain affected by the stroke, strokes effecting larger portions of the brain tend to have more detrimental effects.[7] NIHSS scores have been found to be reliable predictors of damaged brain volume, with a smaller NIHSS score indicating a smaller lesion volume[8]

Item Scoring Definitions
Level of consciousness (LOC) Responsiveness
  • 0 = alert and responsive
  • 1 = arousable to minor stimulation
  • 2 = arousable only to painful stimulation
  • 3 = reflex responses or unarousable
LOC Questions (patient's age and month)
  • 0 = both correct
  • 1 = one correct (or dysarthria, intubated, foreign language)
  • 2 = neither correct
LOC Commands (open/close eyes and then grip/release hand)
  • 0 = both correct (acceptable if impaired by weakness)
  • 1 = one correct
  • 2 = neither correct
Horizontal Eye Movement (voluntary or doll's eye maneuver)
  • 0 = normal
  • 1 = partial gaze palsy; abnormal gaze in one or both eyes
  • 2 = forced eye deviation or total paresis that cannot be overcome by doll's eye maneuver
Visual field (each eye is tested individually)
  • 0 = no visual loss
  • 1 = partial hemianopsia, quadrantanopia, extinction
  • 2 = complete hemianopsia
  • 3 = bilateral hemianopsia or blindness
Facial palsy (in stuporous, check symmetry of grimace to pain)
  • 0 = normal
  • 1 = minor paralysis, flat NLF, asymmetrical smile
  • 2 = partial paralysis (lower face = UMN lesion)
  • 3 = complete paralysis (upper and lower face)
Motor arm (arms outstretched for 10 seconds)
  • 0 = no drift for 10 seconds
  • 1 = drift but does not hit bed
  • 2 = some antigravity effort, but cannot sustain
  • 3 = no antigravity effort, but even minimal movement counts
  • 4 = no movement at all
  • X = unable to assess owing to amputation, fusion, fracture, and so on
Motor leg (raise leg for 5 seconds)
  • 0 = no drift for 5 seconds
  • 1 = drift but does not hit bed
  • 2 = some antigravity effort, but cannot sustain
  • 3 = no antigravity effort, but even minimal movement counts
  • 4 = no movement at all
  • X = unable to assess owing to amputation, fusion, fracture, and so on
Limb ataxia (check finger-nose-finger, heel-shin position sense/score only if out of proportion to paralysis)
  • 0 = no ataxia (or aphasic, hemiplegic)
  • 1 = ataxia in upper or lower extremity
  • 2 = ataxia in upper and lower extremity
  • X = unable to assess owing to amputation, fusion, fracture, and so on
Sensory (check grimace or withdrawal if patient is stuporous)
  • 0 = normal
  • 1 = mild-moderate unilateral loss but patient aware of touch (or aphasic, confused)
  • 2 = total loss, patient unaware of touch; coma, bilateral loss
Best language (describe the scenario in the figure, name objects, read sentences)
  • 0 = normal
  • 1 = mild-moderate aphasia (speech difficult to understand but partly comprehensible)
  • 2 = severe aphasia (almost no information exchanged)
  • 3 = mute, global aphasia, coma; no one-step commands
Dysarthria (read list of words)
  • 0 = normal
  • 1 = mild-moderate; slurred but intelligible
  • 2 = severe; unintelligible or mute
  • X = intubation or mechanical barrier
Extinction or neglect (simultaneously touch patient on both hands/show fingers in both visual fields)
  • 0 = normal, none detected (visual loss alone)
  • 1 = neglects or extinguishes to double simultaneous stimulation in any modality (visual, auditory, sensation, spatial, body parts)
  • 2 = profound neglect in more than one modality

Prognosis

  • Despite aggressive and newer management strategies, the prognosis of patients with intracerebral hemorrhage is very poor.
  • Case-fatality at 1 month is over 40 % and has not improved in last few decades.[9]

References

  1. National Institute of Health, National Institute of Neurological Disorders and Stroke. Stroke Scale. http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf.
  2. NIH Stroke Scale Training,Part 2. Basic Instruction. Department of Health and Human Services, National Institute of Neurological Disorders and Stroke. The National Institute of Neurological Disorders and Stroke (NINDS) Version 2.0
  3. 3.0 3.1 Ver Hage ,. The NIH stroke scale: a window into neurological status. Nurse.Com Nursing Spectrum (Greater Chicago) [serial online]. September 12, 2011;24(15):44-49.
  4. Muir KW, Weir CJ, Murray GD, Povey C, Lees KR (1996). "Comparison of neurological scales and scoring systems for acute stroke prognosis". Stroke. 27: 1817–1820. doi:10.1161/01.str.27.10.1817.
  5. Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC, Broderick JP, Libman R, Levine SR, Brott T (2000). "Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial". Neurology. 55: 952–959. doi:10.1212/wnl.55.7.952.
  6. Dehaan R, Horn J, Limburg M, et al: A comparison of 5 stroke scales with measures of disability, handicap, and quality-of-life. Stroke 1993;24:1178–81
  7. Weimar C, Konig I, Kraywinkel K, Ziegler A, Diener H. "Age and national institutes of health stroke scale score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia - Development and external validation of prognostic models". Stroke. 35 (1): 158–162. doi:10.1161/01.str.0000106761.94985.8b.
  8. Glymour M, Berkman L, Ertel K, Fay M, Glass T, Furie K (2007). "Lesion characteristics, NIH Stroke Scale, and functional recovery after stroke". American Journal of Physical Medicine & Rehabilitation. 86 (9): 725–733. doi:10.1097/phm.0b013e31813e0a32.
  9. Apanasenko BG, Kunitsyn AI, Isaev GA, Khodyrev LP (1976). "[Determination of the weight of disemulsified lipid circulating in the blood as a method of diagnosis of fat embolism]". Lab Delo (1): 41–3. PMID 0056489.


Template:WS Template:WH