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Hemorrhagic Stroke

Hemorrhagic Stroke . Justin S. Cetas MD, Ph.D. Assistant Professor of Neurological Surgery Chief of Neurosurgery PVAMC. Hemorrhagic Stroke . Loosely defined as sudden loss of brain function due to bleeding

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Hemorrhagic Stroke

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  1. Hemorrhagic Stroke Justin S. Cetas MD, Ph.D. Assistant Professor of Neurological Surgery Chief of Neurosurgery PVAMC

  2. Hemorrhagic Stroke • Loosely defined as sudden loss of brain function due to bleeding • Presentation, prognosis, cause and hence treatment vary depending on the location of bleeding • Major Types: epidural, subdural, subarachnoid, intraparenchymal, intraventricular

  3. Intracerebral hemorrhage • Sudden onset focal neurologic abnormality • More often associated with HA, nausea, loss of consciousness, acute severe HTN • CT best and fastest method to distinguish from ischemic stroke

  4. Intracerebral hemorrhage • 10-15% of all strokes • Potential causes include: • Hypertension (majority) • amyloid angiopathy, • AVM or dAVF • aneurysm • use of sympathomimetic drugs (cocaine, methamphetamine) • Vasculitis • Moyamoya disease

  5. Hemorrhagic stroke Hypertension • Most important and prevalent modifiable risk factor • 60-70% of spontaneous ICH • Untreated>treated • Stopping medication>continuing • Brainstem and deep hemispheric locations most common OHSU Neurological Surgery

  6. OHSU Neurological Surgery

  7. OHSU Neurological Surgery

  8. Hemorrhagic Stroke Amyloid • Major cause of lobar hemorrhage • Amyloid protein in media and adventia of arteries, arterioles, and capillaries • Increases with age • 5-8% 60-69 yrs • 57-58% 90yrs or older • Associated with Apolipoprotein E OHSU Neurological Surgery

  9. Hemmorhagic stroke Anticoagulant therapy • OAT for atrial fibrillation common and growing • Increases risk of ICH (0.3-3.7%) • Increases severity and mortality of ICH • Mortality may be as high as 67% OHSU Neurological Surgery

  10. Hemorrhagic stroke other risk factor • Heavy alcohol use • Current tobacco use • Diabetes • Prior cerebral infarct 5-22 fold increase • Hypocholesterolemia • Reduced platelet function • Fragile vessels • Comorbidities • Family history OHSU Neurological Surgery

  11. OHSU Neurological Surgery

  12. OHSU Neurological Surgery

  13. Hemorhagic stroke AVM • 0.5/100,000 • Abnormal vessels draining directly into veins without capillary bed • Mean age at diagnosis 40 • Risk factors: • Prior hemorrhage • Deep location • Deep venous drainage • Venous restrictive disease • Associated aneurysm OHSU Neurological Surgery

  14. Hemorrhagic stroke DAVF • Abnormal shunting of normal arteries into brain • Type I Meningeal arteries – meningeal veins • Type II similar to I with venous reflux • Type III Direct shunting to cortical veins • Type IV venous ectasias • Follow trauma (may be remote) • Can arise spontaneously in the elderly OHSU Neurological Surgery

  15. Case Illustration • 50 year old man experienced sudden headache • He becomes confusedand nauseated • On arrival to ED he become unresponsive • Urgent CT demonstrates IPH, SDH with mass effect

  16. dAVF post op

  17. Hemorrhagic stroke Moyamoya • Progressive stenosis or occlusion of the circle of Willis arteries • Numerous neovessels arise “puff of smoke” • Dilated neovessles form microaneurysms OHSU Neurological Surgery

  18. Hemorrhagic stroke - Moyamoya OHSU Neurological Surgery

  19. Moyamoya • 0.06/100,000 whites • 0.54/100,000 in Japan • Women 2x higher than men • Multiple hemorrhages • Associated with Down’s syndrome OHSU Neurological Surgery

  20. Intracerebral Hemorrhage • Location of hemorrhage • Presence of IVH • Volume of hemorrhage • Best predictor of outcome

  21. ICH Grading scale • Glasgow Coma Scale: • 3-4 2 • 5-12 1 • 13-15 0 • ICH Volume • >30 cc 1 • <30 0 • Infratentorial • Yes 1 • No 0 • Age • >80 1 • <80 0 Mortality Score 26% 2 72% 3 97% 4

  22. Cerebral Aneurysms and SAH • SAH accounts for 3-4% of all strokes (10/100,000) • Fatality approx 50% • 10-15% with sudden death at initial bleed • 40% die within 1 month of admission • 30% of survivors with morbidity • 6% of the population may harbor an aneurysm(s) • ½ of SAH in patients younger than 55

  23. Epidemiology • Modifiable risk factors for SAH: • Hypertension, smoking, excessive alcohol (undefined) • Modifiable risk factors double risk of SAH, contribute to 2/3 cases • Genetic risk factors important in 10% of cases

  24. Cerebral Aneurysms Van Gijn et al. 2007

  25. SAH • Typical presentation • Sudden onset WORST HEADACHE of Life • Rapidly followed by nausea vomiting confusion or coma • High risk of re-rupture • Hydrocephalus

  26. Grading Schemes Hunt Hess Clinical Grade • 1. Asymptomatic, mild headache, slight nuchal rigidity • 2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy • 3. Drowsiness / confusion, mild focal neurologic deficit • 4. Stupor, moderate-severe hemiparesis • 5. Coma, decerebrate posturing

  27. Grading Schemes Fisher Grade: Appearance of hemorrhage on CT • 1 None evident • 2 Less than 1 mm thick • 3 More than 1 mm thick • 4 Any thickness with intraventricular hemorrhage or parenchymal extension

  28. Case Illustration • 49 year old woman experienced sudden onset headache and left arm weakness • Sleepy but oriented and conversant • Transferred to OHSU

  29. OHSU Neurological Surgery

  30. Hemorrhagic stroke • Goals of early intervention • Establish an airway • Blood pressure control • Reverse coagulopathy • Establish the etiology of the hemorrhage • Surgical intervention if indicated

  31. Acute Hypertensive Response • Dramatic rise with ICH • Remains elevated for 24 hours • Current recommendation SBP>160 • SBP>140 may be safe • Too low may exacerbate ischemic injury of adjacent brain OHSU Neurological Surgery

  32. Hemorrhagic Stroke • ICU care is supportive • Aimed at preventing secondary injury • Aggressive ICU care in first 48 hours improves survival and outcomes • Dedicated stroke unit improves survival and recovery

  33. Evacuation of clot • Early evacuation associated with slight increase in rehemorrhage rate • may shorten hospital stay but has no proven impact on long term outcomes except • Mass effect causing further injury • Surgery aimed at preventing secondary injury OHSU Neurological Surgery

  34. Intraparenchymal Hemorrhages • Recovery can take months • Long-term outcomes are difficult to predict early on in disease course • Multi-disciplinary rehabilitation important OHSU Neurological Surgery

  35. Delayed Ischemic Neurological Deficits • Develops 5-15 days after SAH • Risk factors: • Fisher Grade • Age <68 years (elderly may become symptomatic with little spasm) • Smoking, Cocaine use, Hypertension • Genetics: variations in eNOS system

  36. Delayed Ischemic Neurological Deficits • Symptoms may be vague: sleepiness, lethargy or stupor, unexplained fever, diuresis • May be localizing: Hemiparesis, language disturbance, abulia, gaze impairment etc. • Confounders: poor grade, sedation, etc.

  37. Neuro ICU • SAH associated with derrangements of multiple brain systems • Careful monitoring and early intervention critical to preventing infarcts • Improved patient outcomes with dedicated Neuro-ICU

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