Hemorrhagic Stroke
• Approximately 70-80% of all strokes are
ischemic and 20-30% are hemorrhagic
• Hemorrhagic stroke is defined as an acute
neurologic injury resulting from bleeding in
the brain
• There are two distinct types of hemorrhagic
stroke: intracerebral hemorrhage (ICH) and
subarachnoid hemorrhage (SAH).
Hemorrhagic Stroke
Hemorrhagic Stroke
• SAH accounts for 3-5% of all strokes.
• Classically the patient experiences the worst
headache of his or her life. One in 5
patients report a less severe headache in the
hours or days preceding the event.
• The event may be accompanied by focal
neurologic signs, nausea/vomiting, loss of
consciousness, seizure.
Hemorrhagic Stroke
• The most common cause of spontaneous
SAH is the rupture of a cerebral aneurysm,
accounting for about 85% of SAHs.
• Aneurysms tend to occur at the branch
points of cerebral vessels.
• The 30-day mortality is in the range of 33 to
45%.
Hemorrhagic Stroke
• Cerebral aneurysms are present in about 2% of the
population
• Overall the annual risk of rupture is about 0.7%
• Rupture risk is related to aneurysm size and
location.
• The risk of rupture increases significantly for
aneurysms greater than 7 mm in diameter and for
those arising from the posterior communicating
arteries or posterior circulation.
Hemorrhagic Stroke
• 80-85% of aneurysms are located in the
anterior circulation, commonly at the
origins of the posterior or anterior
communicating arteries or the middle
cerebral artery bifurcation.
• Posterior circulation aneurysms most often
occur at the basilar tip or posterior-inferior
cerebellar artery origin.
Hemorrhagic Stroke
Hemorrhagic Stroke
• The factors that strongly influence outcome after
SAH can be divided into patient factors, aneurysm
factors and institutional factors.
• Of the patient factors, by far the most important
determinant is the deleterious effect of acute SAH
on the brain documented by the worst Hunt and
Hess Grade.
Hemorrhagic Stroke
• Hunt and Hess Grade
• Grade 1: Asymptomatic or mild headache and slight
nuchal rigidity
• Grade 2: Moderate to severe headache, stiff neck, no
neurologic deficit except cranial nerve palsy
• Grade 3: Drowsy or confused, mild focal neurologic
deficit
• Grade 4: Stupor, moderate or severe hemiparesis
• Grade 5: Deep coma, decerebrate posturing
Hemorrhagic Stroke
• Other patient factors include age and medical comorbidities, such as hypertension, atrial
fibrillation, congestive heart failure, coronary
heart disease, and renal disease.
• Vasospasm severity, re-hemorrhage, and acute
hydrocephalus are also significantly related to
outcome.
• Aneurysm factors include size and location in the
posterior circulation.
Hemorrhagic Stroke
• Institutional factors include the availability of
endovascular services and the volume of SAH
patients treated.
• With aggressive management of SAH including
emergency ventricular drain placement, ultraearly
aneurysm repair, multidisciplionary medical care
involving intensivists, and endovascular therapies
for vasospasm such as selective infusion of intraarterial vasodilators and balloon angioplasty
approximately half of Hunt and Hess grade V
survivors had cognitive deficits only slightly
reduced compared with the normative population
mean.
Hemorrhagic Stroke
• Patients with a good cognitive outcome
after a severe SAH were significantly
younger (median age 46 versus 52 years),
had more years of education (13 versus 9
years) and had smaller cerebral ventricular
scores.
Hemorrhagic Stroke
• The mainstay of SAH diagnosis is the noncontrast
head CT.
• In the 12 hours after SAH, the sensitivity of CT
for SAH is 98% to 100%, declining to 93% after
24 hours and to 57% to 85% after 6 days.
• Because the diagnostic sensitivity of CT scanning
is not 100%, a lumbar puncture should be
performed if the clinical presentation is suspicious
for a SAH.
Hemorrhagic Stroke
• Cerebral angiography
is currently the
standard for
diagnosing cerebral
aneurysm as the cause
of SAH
Hemorrhagic Stroke
• The selection of surgery versus coiling
depends on several factors including:
•
•
•
•
•
Aneurysm location
Presence of a large hematoma
Aneurysm size
Aneurysm neck size
Patient co-morbidities
Hemorrhagic Stroke
• Intracerebral Hemorrhage (ICH) causes 1015% of first-ever strokes, with a 30-day
mortality rate of 35% to 52%; half of the
deaths occur in the first two days.
• 20% of ICH patients are independent at 6
months.
Hemorrhagic Stroke
• Causes of ICH
• Cerebral aneurysms
• Cerebral arteriovenous
malformations
• Cavernous
malformations
• Moya-moya disease
• Vasculitis
• Hypertension
• Amyloid angiopathy
• Anticoagulants/
antiplatelet agents
• Recreational drugs
• Post-infarction
• Blood dyscrasias
• Idiopathic
• *Brain tumors
• *Unrecognized trauma
Hemorrhagic Stroke
• Hospital admissions for ICH have increased
by 18% over the last ten years
• Increases in the number of elderly people
• Lack of adequate blood pressure control
• Increasing use of anticoagulants and antiplatelet
agents
Hemorrhagic Stroke
• Rapid recognition and diagnosis of ICH are
essential because of its frequently rapid
progression during the first several hours.
• The classic presentation includes the onset
of a focal neurologic deficit, which
progresses over minutes to hours.
• This smooth progression of a focal deficit
over a few hours is uncommon in ischemic
stroke and rare in SAH.
Hemorrhagic Stroke
Initial CT
2’ 45” later
Hemorrhagic Stroke
• Brain imaging is a crucial part of the
emergent evaluation.
• CT and MRI have equal ability to identify
the presence of acute ICH, its size and
location.
• Indications for cerebral angiography include
SAH, abnormal calcifications, obvious
vascular abnormalities and isolated
intraventricular hemorrhage (IVH).
Hemorrhagic Stroke
• Hypertensive vasculopathy is the most common
cause of ICH.
• The underlying mechanism is related to the effects
of systemic blood pressure on small penetrating
arteries that arise from major intracranial vessels.
• In response to hypertension, these small vessels
can develop intimal hyperplasia, intimal
hyalinization and medial degeneration, which
predispose them to focal necrosis and rupture.
Hemorrhagic Stroke
• The classic location of
hypertensive
hemorrhages reflects
the territories supplied
by these small
perforators, with 6065% in the putamen
and internal capsule,
15-25% in the
thalamus and 5-10%
in the pons.
Hemorrhagic Stroke
• Cerebral amyloid angiopathy (CAA) is another
common cause of ICH.
• Strongly associated with age, rarely seen in
patients under 60 years and progressively
increases in incidence after the age of 65.
• CAA is characterized by the deposition of amyloid
beta-peptide in the small and medium-sized
vessels of the cortex with relative sparing of
vessels in the basal ganglia, white matter, and
posterior fossa.
• Affected vessels undergo fibrinoid degeneration,
necrosis and microaneurysm formation.
Hemorrhagic Stroke
• CAA-related
hemorrhages tend to
occur in the cortex
causing lobar
hemorrhages more
often in the temporal
and occipital lobes.
Hemorrhagic Stroke
• Treatment of ICH
• The observation that substantial ongoing
bleeding occurred in patients with ICH and was
linked to neurological deterioration led to
interest in the control of blood pressure and the
use of activated factor VII.
Hemorrhagic Stroke
• Guidelines for the Management of Blood
Pressure
• MAP <110 or SBP<160 and >90 for the first
24-48 hours if no ICP monitor present
• Keep CPP >70 if ICP monitor present
Hemorrhagic Stroke
• Ongoing trials have reported that aggressive
reduction of blood pressure to less than 140 mm
Hg probably decreases the rate of hematoma
enlargement without increasing adverse events.
• However, because the effect on clinical outcome
has not been fully assessed, the more conservative
BP targets should be followed.
• Caution is advised about lowering blood pressure
too aggressively without concomitant management
of CPP.
Hemorrhagic Stroke
• Management of ICP in ICH
• The European Stroke Initiative (EUSI)
guidelines recommend monitoring of
intracranial pressure for patients who need
mechanical ventilation.
• Both the American Stroke Association (ASA)
and EUSI recommend selective use of
mannitol, hypertensive saline and short-term
hyperventilation to maintain the CPP>70.
Hemorrhagic Stroke
• With increasing use of warfarin, oral
anticoagulation (OAC) associated ICH
represents an increasing proportion (up to
17%) of ICH cases and carries a very high
mortality (up to 67%).
• No matter what the indication for warfarin,
the benefits of initial reversal after ICH
always outweigh the risks of stopping OAC.
Hemorrhagic Stroke
• Warfarin doubles ICH mortality
• Warfarin increases risk of hematoma
expansion (OR 6.22)
• Hematoma expansion occurs over more
prolonged time course
Hemorrhagic Stroke
• Reversal of Anticoagulation
• An INR of 1.4 in any ICH patient should be
considered life-threatening.
• Guidelines from US, UK and Australia
recommend
• Prothrombin complex concentrate (PCC)
• Vitamin K
• Fresh Frozen Plasma
Hemorrhagic Stroke
• Vitamin K promotes endogenous clotting factor
synthesis but takes 6h to have an effect.
• PCC has several advantages over FFP including
no need for thawing or compatibility testing,
smaller volumes and higher factor IX levels.
• Although FVIIa can rapidly correct the INR, it
does not replenish all of the vitamin K-dependent
factors and therefore, may not restore thrombin
generation as well as PCC.
Hemorrhagic Stroke
• Seizures after ICH
• Incidence is between 4.6% and 8.2%.
• The routine use of anti-epileptics is not recommended
because of uncertainties about their efficacy and
outcomes.
• Subclinical seizures occur is up to 30% of patients after
ICH. Continuous EEG monitoring should be
considered in ICH patients with a decreased level of
consciousness that is out of proportion to the amount of
brain injury.
Hemorrhagic Stroke
• Venous Thromboembolism Prophylaxis
• Symptomatic and asymptomatic deep vein thrombosis
occurs in 3.7% and 40% of ICH patients respectively.
• All patients with reduced mobility should have SCDs.
• Low molecular weight heparin should be introduced 14 days after the onset of ICH, once cessation of
bleeding has been demonstrated.
Hemorrhagic Stroke
• Management of Blood Glucose
• Maintain euglycemia as with other critically ill
patients (<140 or 150 mg/dl?)
• Avoid large swings in blood glucose
Hemorrhagic Stroke
• Neurosurgery
• Surgical Trial in Intracerebral Hemorrhage (STICH)
randomized 1033 patients with supratentorial ICH to
surgery within 72 h or to conservative management and
demonstrated no outcome benefit from surgery.
• STITCH II is investigating the outcome of surgery for
lobar hematomas <1 cm from the surface or the brain in
patients without IVH.
• Several minimally invasive surgery trials which
combine stereotactic guidance of catheters combined
with thrombolytic enhanced hematoma evacuation are
ongoing.
Hemorrhagic Stroke
• Recommendation for
Surgical Approaches
• Patients with
Cerebellar hemorrhage
>3cm who are
deteriorating
neurologically or who
have brain stem
compression should
have surgical removal
of the clot.
Hemorrhagic Stroke
• For patients with lobar
clots within 1 cm of
the surface, evacuation
of supratentorial ICH
by standard
craniotomy should be
considered.
Hemorrhagic Stroke
• Ventricular drainage should be considered
in all stuporous or comatose patients with
intraventricular hemorrhage and acute
hydrocephalus.
Hemorrhagic Stroke
Hemorrhagic Stroke
• Prognosis of ICH
• 60% of patients with an ICH Score of 0, 50%
with an ICH score of 1, 15% with an ICH score
of 2, 10% with an ICH score of 3 have a
modified Rankin score (mRS) of 1 or 2 at 12
months.
Hemorrhagic Stroke
• In summary, the prevention of clot
expansion is the best way of improving
outcomes from ICH.
• The most effective way of preventing ICH
is blood pressure control and avoiding over
anticoagulation.
• THANK YOU