Raising Awareness of Hemorrhagic Stroke By Kelly A. Taft, RN, BSN Nursing made Incredibly Easy! July/August 2009 2.1 ANCC contact hours Online: www.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Stroke Statistics Third leading cause of death in the U.S. 800,000 Americans experience stroke each year 30% become permanently disabled 20% require institutional care 4 months after the stroke

Definition of Stroke • Hemorrhagic: rupture of a cerebral blood vessel Acute focal neurologic deficit Caused by a vascular disorder that injures brain tissue Two main types: ischemic and hemorrhagic • Ischemic: caused by interruption of blood flow in a cerebral vessel • Hemorrhagic: rupture of a cerebral blood vessel

Hemorrhagic Stroke Spontaneous hemorrhage into the brain Accounts for the minority of cases Most frequently fatal stroke Most common etiology for individuals ages 18 to 45

Hemorrhagic Stroke Causes Intracranial hemorrhage: bleeding directly into brain matter (accounts for 41% of hemorrhagic stroke) • Usually occurs in bifurcations of major arteries • As a result of hypertensive hemorrhage (leads to hyperplasia within the vessel wall, which can lead to “breaks”), atherosclerosis, brain tumors, or certain medications Subarachnoid hemorrhage: bleeding surrounding the brain tissue • From arteriovenous malformation (AVM), trauma, or aneurysm 20% are of unknown etiology

Picturing Two Types of Hemorrhage

Cerebral Aneurysm • Causes: atherosclerosis, congenital defect, Cerebral aneurysm: dilation of the walls of cerebral arteries that develops as result of weakness in the wall • Causes: atherosclerosis, congenital defect, hypertensive vascular disease, and trauma • Commonly affected arteries: internal carotid, anterior cerebral, anterior and posterior communicating, and middle and posterior cerebral

Picturing Cerebral Aneurysm

AVM AVM: complex tangle of abnormal arteries and veins that lack a capillary bed and are linked by one or more fistulas • Blood is shunted from the high pressure arterial system to the low pressure venous system • Exposing the draining venous channels them to high pressures and predisposing them to rupture

Brain Edema Two types: vasogenic and cytotoxic • Vasogenic: influx of fluid and solutes into the brain; develops rapidly after injury • Cytotoxic: cellular swelling occurs in brain ischemia and trauma Brain edema leads to increased intracranial pressure (ICP), tissue shifts, and brain displacement

Major Risk Factors for Hemorrhagic Stroke Obesity Hypertension Cigarette smoking Excessive alcohol intake Genetic predisposition for aneurysm formation Male gender Increased age African American or Hispanic descent

Symptoms of Hemorrhagic Stroke Hemiparesis Confusion Dizziness or loss of balance Difficulty speaking or understanding speech Sudden severe headache Loss of consciousness Nuchal rigidity Visual disturbances Tinnitus

Immediate Complications of Hemorrhagic Stroke Cerebral hypoxia Decreased cerebral blood flow Extension of the area of injury Vasospasm: 40% to 50% of the mortality associated with subarachnoid hemorrhage

Vasospasm Associated with increasing amounts of blood in the subarachnoid cisterns and fissures Leads to increased vascular resistance Impedes cerebral blood flow and causes brain ischemia and infarction Frequently occurring 4 to 14 days after initial hemorrhage Signs & symptoms: worsening headache, decreased LOC, and new focal neurologic deficits

Diagnostic Tests for Hemorrhagic Stroke History and physical exam: • Rapidity of symptoms • Time of onset • Pattern of symptoms • Mental status • Medications patient is taking ECG Complete blood cell count, including platelets Electrolytes Cardiac enzymes and troponin Blood urea nitrogen Creatinine Serum blood glucose Prothrombin time, INR, partial thromboplastin time Oxygen saturation

Imaging Studies for Diagnosing Hemorrhagic Stroke Computed tomography scan: used to determine type of stroke, size, location, and presence of cerebrospinal fluid Cerebral angiography: used to confirm diagnosis of cerebral aneurysm or AVM Lumbar puncture: used to confirm subarachnoid hemorrhage

Hunt-Hess Classification of Subarachnoid Hemorrhages 1: Asymptomatic or mild headache and nuchal rigidity (stiff neck) 2: Cranial nerve (CN) palsy (oculomotor [CN III] or abducens [CN VI]), moderate to severe headache, and nuchal rigidity 3: Mild focal deficit, lethargy, or confusion 4: Stupor, moderate to severe hemiparesis, and early decerebrate rigidity 5: Deep coma, decerebrate rigidity, and moribund appearance Add one grade for serious systemic disease (such as hypertension or chronic obstructive pulmonary disease) or severe vasospasm on angiography

NIH Stroke Scale Important tool in the diagnosis of acute hemorrhagic stroke in patients with sudden onset of symptoms Should be readily available to all healthcare professionals who are in direct contact with patient treatment and identification of stroke

Treatment Goals for Hemorrhagic Stroke Consists of a combination of medical and surgical interventions “Window of opportunity” in which viable brain tissue can be saved Goal of medical treatment is to allow brain to recover from bleeding and prevent or minimize rebleeding

Medical Interventions for Hemorrhagic Stroke Patient should be monitored closely in the ICU Bedrest with sedation to prevent agitation and stress Analgesics for head and neck pain Minimize external stimuli Control of blood glucose levels ICP and BP will be managed Seizure management (as recommended by the AHA)

Surgical Interventions for Hemorrhagic Stroke Removal of hemorrhage via craniotomy (recommended for cerebral hemorrhage greater than 3 cm in diameter) In aneurysms that haven’t ruptured, the surgical goal is to prevent bleeding Less invasive procedures include aneurysm coiling or obstruction

Clipping an Aneurysm

Complications of Hemorrhagic Stroke Rebleeding Psychological symptoms: disorientation, personality changes, amnesia Intraoperative embolization Postoperative artery occlusion Fluid & electrolyte disturbances Gastrointestinal bleeding

Neurologic Nursing Assessment After Stroke Treatment Altered LOC Sluggish pupillary reaction Motor and sensory dysfunction Cranial nerve deficits Speech and vision difficulties Headache, nuchal rigidity, other neurologic deficits Vital sign changes, including an increase or drop in ICP, BP, or heart rate

Rehabilitation After Hemorrhagic Stroke Begins in the acute phase Goal is to return the patient to the highest level of functioning independently while improving quality of life Focus on home and community capabilities Works best when patient, family, and healthcare providers work as a team

Rehabilitation Components Preventing complications Treating disabilities Improving function Providing adaptive tools Altering the environment as appropriate Patient/family teaching

Patient and Family Teaching Signs and symptoms of stroke Measures to prevent subsequent strokes Potential complications Psychosocial consequences Safety measures to prevent falls Medications Adaptive techniques Appropriate exercise Diet modifications How to measure BP and when to report to healthcare provider Importance of keeping follow-up appointments