Hemorrhagic Stroke | Lisa Klein

Aug 26, 2023

Hemorrhagic Stroke | Lisa Klein

In this installment of the Sheikh Khalifa Stroke Institute (SKSI) webinar series, Lisa Klein, MSN, RN, AGCNS-BC, CNRN, reviews the types of hemorrhagic stroke, lists the signs and symptoms of a hemorrhagic stroke and discusses concerns for patients with this condition.

Content

2.01 -> >> Now to go over hemorrhagic strokes.

5.15 -> The objectives of this presentation

7.15 -> is that you will be able to list

8.37 -> the two types of hemorrhagic strokes,

10.54 -> list the signs and symptoms,

12.21 -> and three concerns for patients experiencing

14.53 -> a hemorrhagic stroke.

17.44 -> Hemorrhagic strokes account

18.86 -> for about 15 to 20% of all strokes.

22.02 -> And when a patient has a hemorrhagic stroke,

24.1 -> this is due to a rupture of a weakened blood vessel

26.67 -> that bleeds into the brain tissue.

28.49 -> But depending on where that blood vessel is that leaks,

32.53 -> that will tell us which type of hemorrhagic stroke we have.

35.17 -> So the first type we have

36.333 -> is a subarachnoid hemorrhage or an SH.

39.41 -> This accounts for 41% of strokes.

42.09 -> When we think of subarachnoid,

44 -> we think of the subarachnoid space,

46.09 -> and this is part of your meninges around your brain.

48.69 -> When you have bleeding into this space,

50.67 -> is primarily the result of cerebral aneurysm or trauma.

55.49 -> Something to note is that patient

57.44 -> that has a subarachnoid hemorrhage due to a trauma

59.95 -> is not considered part of our stroke program.

64.45 -> If a patient has a subarachnoid hemorrhage

65.93 -> that is due to a vascular issue or weakness,

69.41 -> then it is included in our stroke program.

72.18 -> For intracerebral hemorrhages,

73.5 -> this accounts for a larger percentage

75.09 -> of our hemorrhagic strokes, that's 60%,

77.75 -> and to be included in our stroke program,

80.11 -> it has to be a spontaneous non-traumatic bleeding directly

83.2 -> into the brain tissue or the brain prank them up.

86.42 -> When it comes to hemorrhagic strokes,

87.91 -> there are higher rates of morbidity

89.52 -> and mortality compared to ischemic strokes.

93.53 -> As far as risk factors for hemorrhagic stroke,

96.02 -> ones within your control include hypertension,

98.85 -> which once again is the number one risk factor,

101.27 -> as same as ischemic stroke.

103.16 -> As well, we have smoking, excess of alcohol intake,

106.36 -> liver and kidney disease, drug abuse, brain tumors,

110.7 -> bleeding disorders, and blood vessel abnormalities,

113.74 -> which could include aneurysms,

116.07 -> arterial venous malformations, patients who have vasculitis

120.3 -> and amyloid angiopathy or (mumbles) disease.

126.168 -> Outside of your control risk factors include age and gender.

130.61 -> As far as age, the incidence increases after the age of 45.

134.93 -> And for gender more men compared to women have a stroke,

139.41 -> have an hemorrhagic stroke, sorry.

141.59 -> As far as the signs and symptoms,

143.62 -> you might have a lot of the similar signs and symptoms

145.84 -> of an ischemic stroke,

146.89 -> but these are some additional ones you might see.

148.92 -> So you still might have cranial nerve deficits.

151.45 -> We might see a facial droop and other focal deficits,

154.42 -> but the patient may experience a sudden severe headache,

157.47 -> this worst headache of their life.

159.66 -> And then they sometimes call it the Thunderclap headache.

162.64 -> As well, patients may experience nausea and vomiting.

165.65 -> They might have a loss of consciousness, onset of confusion,

169.76 -> weakness on one side, vision changes,

172.29 -> might have photophobia, difficulty speaking

174.99 -> or understanding speech, stiff neck or neck pain

178.64 -> and your patient may experience a seizure prior to having,

182.14 -> coming in and being identified

183.74 -> as having a hemorrhagic stroke.

186.38 -> As far as the diagnosis of hemorrhagic stroke,

189.08 -> we first, because the patient comes in,

191.17 -> if they're looking like they're having a stroke,

192.92 -> we're gonna get a dry non-contrast CT.

196.34 -> And here where we can see here on the picture to the right,

199 -> the white area of where we have a bleed.

201.781 -> Patients might also get a CTA

203.87 -> or other types of angiography like MRI angiography,

206.86 -> or cerebral angiography.

208.5 -> And this just helps get a better picture of the vasculature

211.01 -> to see what the source of the bleed is from.

214.2 -> Patients as well might get a lumbar puncture

216.28 -> cause sometimes these bleeds can actually

217.99 -> also go into the ventricles and we might need

220.91 -> to see if there is blood in the ventricles.

224.21 -> If we're sort of unsure on the scans.

227.61 -> With regards to subarachnoid hemorrhages,

229.7 -> this accounts for about 5% of all strokes,

232.73 -> and this is where we have blood vessels outside of the brain

235.44 -> that ruptured causing blood

237.23 -> to fill in the subarachnoid space.

239.49 -> It is frequently caused by abnormalities of the arteries

242.39 -> at the base of the brain, especially our cerebral aneurysms

245.43 -> and this accounts for about 85%.

247.67 -> As well might be caused from arteriovenous malformations

250.79 -> and trauma, as I said, trauma is not included as something

253.8 -> that we can necessarily prevent as part of a stroke.

257.39 -> Subarachnoid hamburgers also can extend to the ventricles

261.39 -> if a subarachnoid hemorrhage spreads to the ventricles,

264.33 -> it is associated with a poor outcome for patients.

268.5 -> So there's the picture.

269.57 -> Here we can see the subarachnoid space

271.68 -> and that middle layer of the meninges.

274.87 -> As far as aneurysmal subarachnoid hemorrhage epidemiology,

278.28 -> there's about 28,000 aneurysmal subarachnoid hemorrhages

282.1 -> per year in the United States.

284.25 -> And actually an autopsy studies, patients,

286.85 -> people who are non-symptomatic of having an aneurysmal bleed

291.441 -> actually 5% of the general population will find that

295.67 -> they have an aneurysm in autopsy studies.

299.62 -> Aneurysmal subarachnoid hemorrhages affects more women

301.57 -> than men with a three to two ratio

303.4 -> with mean age onset of 30 to 60 years.

306.03 -> 10 to 15% of patients that have

308.91 -> an SAH die before reaching the hospital.

312.17 -> And about 50% of survivors have major disability.

316.81 -> As far as risk factors for subarachnoid hemorrhage,

319.57 -> once again hypertension is the number one risk factor.

322.98 -> Other ones include cigarette smoking, oral contraceptives,

326.55 -> pregnancy or the patrician period,

329.02 -> a history of cocaine abuse as you're increasing with age

332.4 -> and any of these types

334.05 -> of inherited connective tissue disorders.

337.8 -> We have some surgical treatment options for aneurysms.

340.53 -> So we can do a surgical clipping.

342.41 -> This is where we actually have to do a craniotomy

344.41 -> and go through the tissue to actually clip, put a clip.

347.57 -> As we can see here in the picture to the right,

349.93 -> and this will be on the neck of this berry aneurysm,

353.34 -> and then another option is endovascular coiling or stenting.

356.81 -> And it could be both with the coiling,

359.2 -> we have a microcatheter that gets threaded

361.41 -> to the aneurysm through an artery.

363.75 -> They'll fill the aneurysm with coils, they'll heat them up,

367.46 -> and this will help to obstruct the flow to the brain.

370.4 -> And as I said, you might also have a stent with the coiling.

373.44 -> So you have the coiling go in and then they put a stent

376.46 -> in place to have the blood flow be diverted

379.18 -> so it doesn't go into

380.11 -> that weakened outpouching of the vasculature.

383.81 -> With intracerebral hemorrhages.

385.11 -> This is where we have bleeding within the brain tissue

387.33 -> or the brain parenchyma.

389.08 -> And we see this most frequently in our cerebral lobes,

392.75 -> the basal ganglia, the thalamus, pons, the cerebellum,

396.89 -> and it can't extend also to the ventricles in the brain.

401.58 -> It is common to have bleeding in the cerebral lobes,

406.27 -> from the arteries of the anterior middle

408.75 -> and posterior cerebral arteries.

412.19 -> As far as the prevalence of ICH is,

414.07 -> it occurs in about 40 to 50,000 persons in the U.S. a year.

418.23 -> There's an up to 50% mortality study within a month

421.92 -> and an up to 50% disability at a year.

425.06 -> There is an increased incidence in ICH is among males.

429.93 -> When your age is greater than 55

432.77 -> and those of black and Japanese ethnicity.

438.18 -> Common causes of ICH include hypertension,

441.698 -> arterialvenous malformations and once again,

444.17 -> trauma to the head.

446.1 -> When patients have bleeds, main concerns with the patients

449.57 -> who's had hemorrhagic stroke are mainly these few things.

453.24 -> So first off we can say, we're concerned with vasospasms.

456.65 -> And this is where we have delayed cerebral ischemia.

458.96 -> When you think of spasms, you can think of the vascular sort

461.68 -> of clamping down and opening, so it clamps down and opens.

466.15 -> And what happens is if you see on the picture to the right,

469.2 -> where the picture B further to the right,

472.18 -> you can see nice big open vasculature,

475.65 -> but then in the picture to the left in A,

478.05 -> you can see the same sort of in the middle.

480.65 -> It has collapsed and it's really small.

482.95 -> What happens is this is sort of like having constriction

485.21 -> and dilation happening is that you can actually

487.63 -> cause a patient that has a hemorrhagic stroke

490.14 -> to actually have an ischemic stroke as well

492.27 -> cause you're causing ischemia

493.44 -> with the clamping down of the vasculature.

495.73 -> These assess spasms usually onset within a by day,

499.74 -> around day 4 to 14 after a bleed.

502.89 -> And it peaks after subarachnoid hemorrhage

505.31 -> around days six to eight, but patients remain at risk

508.42 -> for up to 21 days.

510.19 -> When a patient has had a subarachnoid hemorrhage,

512.04 -> we frequently have transcranial doppler done daily

515.63 -> to see if a patient is having vasospasms.

518.17 -> To make sure that we're treating the basal spasms,

520.8 -> usually giving patients extra fluid to maintain

523.74 -> the amount of fluid in the vasculature.

526.49 -> We're also concerned for patient's re bleeding.

529.07 -> So patient, if they have blood in their brain,

531.43 -> it may just form a clot and end there,

533.86 -> but we're worried if the bleed increases

536.5 -> and if it increases, this is the point that we can have

539.65 -> the blood starts acting like a mass occupying lesion,

542.95 -> and we have what's called mass effect.

545.01 -> So we'll start, we could start seeing

546.46 -> some compression on the brainstem.

548.19 -> Remember the brainstem is where you're controlling

550.2 -> your breathing and your pulse.

552.19 -> In these patients are at much higher risk

554.817 -> where they need to be intubated.

556.51 -> And then as well, when you have brain tissue being pushed

559.59 -> to the side because of blood there,

561.66 -> you're risking your patients having

563.73 -> any of a numerous types of herniation syndromes.

566.77 -> Also when there's blood in the brain,

569.02 -> the blood that's there, it causes tissue damage

571.96 -> and can cause some cerebral edema.

573.93 -> And there's also some neurotoxic release.

576 -> So even the healthy brain that is around the blood,

579.84 -> that can be irritated also from the blood

581.767 -> and we can have damage to the tissue from that.

584.8 -> As well when we have a subarachnoid hemorrhage

587.31 -> or an ICH that goes into the ventricles,

591.24 -> if we have blood that collects there and it prevents

594.66 -> the CSF from flowing down through your ventricles

597.86 -> and then around to your spinal cord and around your brain,

601.01 -> we can then deal with patients

602.36 -> having obstructive hydrocephalus,

604.41 -> which has major concern for patients

605.93 -> when they've had bleeds.

608.28 -> Next up, we'll do a review

609.52 -> of The National Institute Of Health Stroke Scale,

612.16 -> and also do go over nursing care of a stroke patient.

Source: https://www.youtube.com/watch?v=f8HSNJr3sVc