Hemorrhagic stroke resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Definitions

Hemorrhagic Stroke

Hemorrhagic stroke is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. It is important to note that only non-traumatic causes of CNS hemorrhages are classified as stroke. Hemorrhagic stroke consists of:

Intracerebral Hemorrhage (ICH)

This is defined as a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. Therefore, it consists of:

• Intraparenchymal hemorrhage
• Intraventricular hemorrhage
• Parenchymal hemorrhages following CNS infarction

Type I - confluent hemorrhage limited to ≤30% of the infarcted area with only mild space-occupying effect.

Type II - >30% of the infarcted area and/or exerts a significant space-occupying effect.

Subarachnoid Hemorrhage (SAH)

This is defined as bleeding into the subarachnoid space (the space between the arachnoid membrane and the pia mater of the brain or spinal cord). This consists of:

• Aneurysmal SAH
• Non-aneurysmal SAH

Time of Onset

Time of onset is defined as when the patient was last awake and symptom-free or known to be “normal".

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• All the causes of stroke are life-threatening.

Common Causes

• Hypertension
• Bleeding disorders
• Illicit drug use (e.g., amphetamines or cocaine)
• Trauma
• Vascular malformations
• Rupture of arterial aneurysms

Management

Diagnosis

Check vitals Stabilize ABC Brief Hx Rapid physical exam - neuro exam, NIHSS Activate stroke team Stat fingerstick Basic labs, troponin, EKG NPO Obtain stroke protocol

Non-contrast CT (or MRI)

Bleed

Positive

Negative

Ischemic Stroke

Intracerebral Hemorrhage

Subarachnoid Hemorrhage

Strong Suspicion for SAH

Management of ICH

May consider lumber puncture

Management of SAH

Xanthochromia or bloody CSF

Yes

No

No SAH

Strong Suspicion for SAH

Traumatic tap? Poor Technique?

Yes

No

CTA/MRA Consult to Neurosurgeon Talk with superior

Normal CSF

Obtain more Hx and Investigation Rule out other causes Analgesia

Intracerebral Hemorrhage

Hx & PE suggestive of hemorrhage Stabilize ABC Assess GCS CT confirmed CNS bleed Consult to ICU, Neurosurgery CBC, BMP, PT/PTT/INR/Fibrinogen, Type & CM NPO

Medical Management

Surgical Management

Coagulopathy

BP Control

Elevated ICP

Hydrocephalus IVH

Cerebellar Hemorrhage

Lobar Hematoma (clots) >30mls

If >3cm or Any size with neurological deterioration or Brainstem compression and/or hydrocephalus from ventricular obstruction

If >1cm and accessible (within 1cm from surface)

Ventricular drainage

May Consider Surgical Evacuation

May Consider Craniotomy

Supportive Care

Nurse in NICU, IVF - N/S Manage Hyperglycemia with Insulin (aim between 80-110 mg/dL) Temp <37.5 deg C BP Control <140/90 DVT Prophylaxis - Intermittent pneumatic compression + elastic stockings Seizure Control - IV Fosphenytoin or phenytoin Loading dose - 10-20mg PE/Kg slowly over 30 mins (max 150mg PE/min Maintenance dose - 4-6mg PE/Kg/day in divided doses

Blood Pressure

Blood Pressure Management

SBP >200 mmHg or MAP >150 mmHg

SBP >180 mmHg or MAP >130 mmHg

Monitor BP every 5 mins Continuous IV antihypertensive infusion

Evidence/Suspicion of Elevated ICP

YES

NO

ICP Monitoring Maintain CPP ≥60 mmHg Intermittent or Continuous

Intermittent/Continuous Infusion Aim at MAP of 110 mmHg or BP of 160/90 mmHg Check vitals every 15 mins

Dos

• Acute lowering of blood pressure to a systolic BP of 140 mmHg is safe and recommended for SBP between 150 and 220 mmHg.

Don'ts

• No place for prophylactic anti-convulsants.