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

2. 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

3. 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

4. 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

5. 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

6. Picturing Two Types of Hemorrhage

7. 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

8. Picturing Cerebral Aneurysm

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. Clipping an Aneurysm

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

24. 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

25. 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

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

27. 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