Hemorrhagic stroke natural history

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

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:

• The mass effect from the hematoma itself
• Activation of the coagulation cascade and release of inflammatory cytokines, and blood-brain barrier (BBB) disruption

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. 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.

Score	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. 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. NIHSS scores have been found to be reliable predictors of damaged brain volume, with a smaller NIHSS score indicating a smaller lesion volume

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.
• However, some studies suggested that excellent medical care has a direct impact on intracerebral hemorrhage (ICH) morbidity and mortality.
• Case-fatality at 1 month is over 40 % and has not improved in last few decades.

Prognostic factors

Intracranial hemorrhage

Prognsostic factors in Intracerebral hemorrhage include:

Poor prognostic factors	Associations
Fever	Associated with early neurologic deterioration
Higher initial blood pressure	Associated with early neurologic deterioration and increased mortality
Higher creatinine	hematoma expansion
Higher serum glucose	Associated with hematoma expansion and worse outcome
Warfarin-related hemorrhages	Associated with an increased hematoma volume, greater risk of expansion, and increased morbidity and mortality
warfarin therapy with an INR >3	Associated with larger initial hemorrhage volume as well as poorer outcomes

Subarachnoid hemorrhage

The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.

Grading	Associations	Survival
Grade 1	Asymptomatic Minimal headache and slight neck stiffness	70% survival
Grade 2	Moderate to severe headache Neck stiffness No neurologic deficit except cranial nerve palsy	60% survival
Grade 3	Drowsy Minimal neurologic deficit	50% survival
Grade 4	Stuporous Moderate to severe hemiparesis Early decerebrate rigidity Vegetative disturbances	20% survival
Grade 5	Deep coma Decerebrate rigidity Moribund	10% survival

References

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