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Hemorrhagic Stroke Part 1

April 12, 2022

For those following the neurological diseases course with us: This is the fourth meeting, and it is about hemorrhagic strokes - Part One. Slides for Meeting 4: https://jpuedu-my.sharepoint.com/:b:/g/personal/eyad_aqunaibi_jpu_edu_jo/EWZ73MyAC-RLms_WDDxP0z4B-ZTM-T0OHw_qp-I7VmJ28g?e=Zr8i3I

Introduction and Lecture Objectives

With God's blessing, we begin today the first part of the topic of hemorrhagic stroke (Hemorrhagic Stroke). In this meeting, we will discuss the definition of hemorrhagic stroke, specifically the type "intraparenchymal hemorrhage" (Intraparenchymal Hemorrhage), in terms of definition, epidemiological spread (Epidemiology), causes, how to diagnose the patient and the symptoms they complain of, up to treatment methods. We will also discuss two clinical cases to illustrate the practical aspects.

Case Study (1): The Danger of Self-Diagnosis and Aspirin

We begin by discussing the case of an 80-year-old woman who suffered a sudden and severe headache on the left side of her head without other symptoms. Her husband gave her two aspirin tablets at home, thinking it was a treatment for the headache, but there was no improvement. The next day, he repeated giving her two additional aspirin tablets. On the third day, the patient woke up suffering from weakness on the right side of her body, which necessitated her immediate transfer to the hospital.

Upon arrival, and due to the presence of stroke symptoms (weakness on the right side), a CT scan of the brain (CT scan without contrast) was performed. The scans showed a large hemorrhage (approximately 7 cm) on the left side of the brain. It is clear here that one of the major mistakes was giving aspirin as a treatment for the headache; as aspirin can lead to worsening of the hemorrhage and increasing its size, especially since the patient on the first day did not suffer from motor weakness, indicating that the size of the hemorrhage doubled after taking aspirin.

Definition of Stroke and Its Types

For reminder, stroke (Stroke) is divided into two main types based on the mechanism of its occurrence:

Ischemic Stroke: Occurs as a result of blockage in the arteries that prevents blood from reaching the brain, and accounts for approximately 85-87% of cases.
Hemorrhagic Stroke: Occurs as a result of a burst artery and blood leaking from it, and accounts for approximately 13-15% of cases.

It is not necessary in the definition of stroke that there is permanent death of brain tissue (Death of brain tissue) if intervention is made in time, especially in cases of ischemic stroke when using clot-dissolving agents (tPA) or mechanical thrombectomy (Thrombectomy), where the patient can achieve full recovery.

Types of Intracranial Hemorrhage

The term "intracranial hemorrhage" is used as a general term that includes several types, while we use the term "hemorrhagic stroke" to refer to specific types. Types of hemorrhage are:

Epidural Hematoma: Occurs between the skull and the dura mater (Dura mater), and is usually caused by injury or skull fracture.
Subdural Hematoma: Occurs under the dura mater and between the arachnoid layer (Arachnoid).
Subarachnoid Hemorrhage: Occurs under the arachnoid layer.
Intraparenchymal / Intracerebral Hemorrhage: This is the hemorrhage that occurs within the brain tissue itself.

What we consider medically as "hemorrhagic stroke" are the third and fourth types (subarachnoid hemorrhage and intraparenchymal hemorrhage).

Anatomy of Brain Layers

For illustration, the brain is covered by three layers (meninges):

Dura Mater: The outer layer directly under the skull.
Arachnoid Mater: The middle layer.
Pia Mater: The thin layer adherent to the brain tissue.

The hemorrhage that causes a stroke is the one that occurs in the brain tissue or in the subarachnoid space, while the hemorrhage above or below the dura mater is usually a result of accidents and injuries (Trauma) and is not classified as a traditional stroke.

Epidemiology and Causes of Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage accounts for approximately 60% of hemorrhagic stroke cases. In the United States, between 40,000 to 50,000 cases are recorded annually. The mortality rate (Mortality) is high and reaches 50%, and the rate of disability (Disability) after hemorrhage also reaches 50%. It is noted that the incidence is more common among men and in ages exceeding 55 years.

Main Causes (Etiology):

Hypertension: Is the main cause and responsible for 80% of cases, especially in age groups under 60 years. Controlling blood pressure is the most important means of prevention.
Cerebral Amyloid Angiopathy: Resulting from the deposition of "beta-amyloid" protein on the walls of arteries, weakening them, and is common in those over 60 years and associated with Alzheimer's disease.
Other Causes (10%): Include coagulation disorders, use of blood thinners (such as warfarin or heparin), complications resulting from clot-dissolving agents (tPA), metastatic brain cancers, and vascular malformations (AVM).

Common Sites of Hypertension-Induced Hemorrhage

Hypertension-induced hemorrhage occurs in specific locations within the brain, the most important of which are:

Basal Ganglia: This is the most common site (approximately 80% of cases). Since this area carries the neural pathways responsible for motor strength, the patient usually shows weakness in the limbs.
Thalamus: Since it is the center of sensation, the patient here complains of loss of sensation on one side of the body.
Brainstem: Specifically the "pons" area, which is a very dangerous area as it contains vital centers, and hemorrhage in it can lead to rapid death.
Cerebellum: The patient usually presents with headache, vomiting, and lack of balance (Ataxia). The danger of cerebellar hemorrhage lies in the narrow space around it, which may lead to pressure on the brainstem.

Symptoms and Diagnosis

Clinical Symptoms (Presentation):

Headache: Appears in 40% of patients as an initial symptom, which distinguishes hemorrhage from ischemic stroke, which usually does not begin with sudden headache.
Change in Consciousness Level: The patient may be confused (Confused) or completely unconscious.
Local Neurological Symptoms: Such as motor weakness or loss of speech.
Seizures: Occur in approximately 7% of cases, especially if the hemorrhage is near the brain cortex (Cortex).

Diagnosis (Diagnosis):

Upon the patient's arrival at the emergency department, the following tests are performed:

CT Head Scan: This is the first and primary examination to detect the presence of blood, determine its size, and find out if there is a shift in the midline (Midline shift) or hydrocephalus (Hydrocephalus).
CT Angiogram: To ensure that there is no vascular dilation (Aneurysm).
Laboratory Tests: Include complete blood count (CBC), liver function tests, and blood clotting tests (INR).
Magnetic Resonance Imaging (MRI): This is performed later (not usually in an emergency) if there is suspicion of tumors or venous clots.

Management (Management)

The treatment plan depends on the stability of the condition and preventing the worsening of the hemorrhage:

1. Medical Management:

Securing the Airway: If the patient is unconscious or the bleeding is near the brainstem, artificial respiration (Intubation) is performed.
Blood Pressure Control: This is the critical point; high blood pressure is lowered using intravenous drugs such as (Nicardipine) or (Labetalol).
Reversing Anticoagulation: If the patient is taking blood-thinning medications, they must be given antidotes immediately (such as Vitamin K or PCC for Warfarin).
Deep Vein Thrombosis (DVT) Prophylaxis: The use of heparin is strictly prohibited in the acute bleeding phase, and sequential compression devices (SCD) for the legs are relied upon entirely.

2. Surgical Management:

Surgical intervention is performed in certain cases:

Decompressive Craniectomy: If the bleeding is very large and presses on vital centers or causes brain herniation.
External Ventricular Drainage (EVD): If blood reaches the brain ventricles and causes obstruction of cerebrospinal fluid flow (Hydrocephalus), an external tube is placed to drain the blood and fluid.

Managing Seizures

As mentioned, if the bleeding is near the cerebral cortex, the likelihood of seizures increases. In these cases, we start by administering antiepileptic drugs for prophylaxis (such as Keppra).

In the intensive care unit, we use an electroencephalogram (EEG) to monitor the patient, especially if they do not regain consciousness after withdrawing sedatives, to detect "non-convulsive status epilepticus," where the brain is in a continuous seizure state without obvious body movements. This condition requires immediate treatment to prevent brain damage.

Case Study (2): Basal Ganglia Hemorrhage and Blood Pressure Control

We will now discuss the case of a 55-year-old patient with a history of hypertension. She arrived at the emergency department with persistent vomiting, indicating that she had suffered a severe and sudden headache the previous night, which she had never experienced before—a "red flag" that warrants immediate examination.

Upon examination, her blood pressure was very high (181/105), and she had impaired consciousness and weakness on the right side of her body. The CT scan showed bleeding in the "basal ganglia" on the left side of the brain, a typical location for hypertension-induced bleeding.

Treatment Plan for the Case:

Securing the Airway: Due to the deterioration in consciousness, the patient was placed on a ventilator (Intubation) to protect the airway, and the drug "Propofol" was used for sedation.
Blood Pressure Control: Intravenous doses were immediately started to lower and control the blood pressure.
Intensive Care Monitoring (ICU): The patient was transferred to the ICU, where nursing staff perform a neurological examination every hour. For clarification, even while the patient is on a ventilator, we can assess their consciousness by asking simple commands such as "open your eyes" or "squeeze my hand."
Avoiding Anticoagulants: All blood-thinning medications the patient was taking at home were stopped, and mechanical compression devices for the legs (SCD) were used to prevent venous thrombosis.
Case Progression: On the second day, the CT scan showed a slight increase in the size of the hemorrhage with surrounding edema and a slight shift in the midline by 3 mm.

Managing Cerebral Edema:

Since the bleeding did not reach the brain ventricles, there was no need for surgical intervention to drain the blood. However, to manage the edema and midline shift, "hypertonic saline solution" was administered. The goal of this solution is to raise the sodium level in the blood (to 145-150 mEq/L) to draw fluid from the swollen brain tissue and reduce internal pressure.

Recovery and Device Discontinuation:

On the fourth day, after stabilizing the radiological readings and controlling the blood pressure, the sedatives were stopped to evaluate the patient. The patient responded well to commands, allowing the removal of the breathing tube (Extubation) on the fifth day. By the sixth day, the patient was fully awake and her clinical condition was stable.

Additional Discussions and Frequently Asked Questions

Should We Administer Antiepileptic Drugs Prophylactically to All Patients?

In the previous case, antiepileptic drugs were not administered because the bleeding was deep in the basal ganglia and far from the cerebral cortex. The general rule is to start prophylactic treatment if the bleeding is cortical or very close to the cortex, as this area is responsible for generating the electrical charges that cause seizures.

Use of Electroencephalogram (EEG) in Intensive Care:

The availability of an EEG machine in intensive care units is vital for patients with brain hemorrhage. Often, the patient does not regain consciousness despite the stabilization of the hemorrhage, and the cause may be non-convulsive seizures that can only be detected by continuous monitoring for 24 or 48 hours.

Conclusion:

The key to success in treating hemorrhagic stroke lies in:

Rapid diagnosis with CT scans.
Strict and rapid control of blood pressure.
Precise neurological monitoring in the intensive care unit.
Avoiding fatal mistakes such as administering heparin or aspirin in the acute phase.

With this, we have completed the first part of the topic on hemorrhagic stroke, and we will continue in the next meeting, God willing, discussing "subarachnoid hemorrhage."

Peace be upon you and the mercy of God and His blessings.