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Hemorrhagic Stroke
Counselor,

The terms intracerebral hemorrhage (ICH) and hemorrhagic stroke are used interchangeably in this discussion and are regarded as a separate entity from hemorrhagic transformation of ischemic stroke. ICH accounts for 10- 15% of all strokes and is associated with higher mortality rates than cerebral infarctions. Patients with hemorrhagic stroke present with similar focal neurologic deficits but tend to be more ill than patients with ischemic stroke. Patients with intracerebral bleeds are more likely to have headache, altered mental status, seizures, nausea and vomiting, and/or marked hypertension; however, none of these findings distinguish reliably between hemorrhagic and ischemic strokes.

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Pathophysiology:
In ICH, bleeding occurs directly into the brain parenchyma. The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension. Other mechanisms include bleeding diatheses, iatrogenic anticoagulation, cerebral amyloidosis, and cocaine abuse. ICH has a predilection for certain sites in the brain, including the thalamus, putamen, cerebellum, and brain stem. In addition to the area of the brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by the mass effect of the hematoma. A general increase in intracranial pressure may occur.

Frequency/Mortality/Morbidity:
ICH accounts for 10-15% of all strokes. Recent reports indicate an incidence exceeding 500,000 new strokes of all types per year. Stroke is a leading killer and disabler. Combining all types of stroke, it is the third leading cause of death and the first leading cause of disability. Morbidity is more severe and mortality rates are higher for hemorrhagic stroke than for ischemic stroke. Only 20% of patients regain functional independence. The 30-day mortality rate for hemorrhagic stroke is 40-80%. Approximately 50% of all deaths occur within the first 48 hours.

History:
Patients' symptoms vary depending on the area of the brain affected and the extent of the bleeding. Hemorrhagic strokes are more likely to exhibit symptoms of increased intracranial pressure than other types of stroke. Headache, often severe and sudden onset with nausea and/or vomiting occur with some frequency. Seizures are more common in hemorrhagic stroke than in ischemic stroke. They occur in up to 28% of hemorrhagic strokes and generally occur at the onset of the ICH or within the first 24 hours.

Physical:
Intracerebral hemorrhage (ICH) may be clinically indistinguishable from ischemic stroke. Hypertension commonly is a prominent finding. An altered level of consciousness or coma is more common with hemorrhagic strokes than with ischemic strokes. Often, this is due to an increase in intracranial pressure.

Meningismus may result from blood in the ventricles. Focal neurologic deficits depends upon the area of brain involved. If the dominant hemisphere (usually left) is involved, a syndrome consisting of right hemiparesis, right hemisensory loss, left gaze preference, right visual field cut, and aphasia may result.

If the nondominant (usually right) hemisphere is involved, a syndrome of left hemiparesis, left hemisensory loss, right gaze preference, and left visual field cut may result. Nondominant hemisphere syndrome also may result in neglect when the patient has a left-sided hemi-inattention and ignores the left side.

If the cerebellum is involved, the patient is at high risk of herniation and brainstem compression. Herniation may cause a rapid decrease in the level of consciousness, apnea, and death.

Causes:
Hypertension is the major cause (up to 60% of cases). Other causes and factors include advanced age (risk factor), cerebral amyloidosis (affects people who are elderly and may cause up to 10% of ICHs), coagulopathies (e.g.: due to underlying systemic disorders), anticoagulant therapy, thrombolytic therapy for acute myocardial infarction (MI) and acute ischemic stroke (can cause iatrogenic hemorrhagic stroke), abuse of cocaine and other sympathomimetic drugs, arteriovenous malformation, intracranial aneurysm, vasculitis, intracranial neoplasm, and bleeding due to a brain tumor.

Lab and Imaging Studies:
These include: complete blood count, coagulation profile, electrolytes, serum glucose, blood type and screen. Imaging studies include: Noncontrast CT of the brain and MRI. MRI, especially newer techniques such as diffusion-weighted imaging, has been shown to identify ischemic stroke earlier and more reliably than CT scanning. MRI is being utilized with increasing frequency in the evaluation of ischemic stroke.

Treatment:
Airway, breathing and circulation should always be assessed first. Heart monitoring should be established and the patient should have an IV started and oxygen administered. An ECG should be obtained. Bedside glucose testing should be performed because hypoglycemia can mimic stroke. Prophylactic anticonvulsant therapy is often advised. Dilantin is the drug of choice. Blood pressure should be carefully monitored. Although BP elevations may risk further hemorrhage, too rapid or aggressive BP lowering may compromise cerebral perfusion.

The American Heart Association guidelines recommend intravenous antihypertensive treatment for patients with mean arterial pressure (MAP) > 130 mm Hg. MAP should be maintained above 90 mm Hg to ensure adequate cerebral perfusion.

Intubation should be performed for patients who demonstrate potential loss of airway protective mechanisms or signs of brainstem dysfunction. If intubation is needed, rapid sequence intubation should be performed with technique and medications aimed at limiting any increase in intracranial pressure.

Currently, no effective targeted therapy for hemorrhagic stroke exists. However, some preliminary research indicates that treatment with hemostatic therapy may be effective. A recent preliminary study of treatment with recombinant factor 8 demonstrated reduced mortality and improved functional outcomes. Further studies are necessary to determine if this should be accepted as a clinical treatment option.

A potential treatment of hemorrhagic stroke is surgical evacuation of the hematoma. The role of surgical treatment for supratentorial intracranial hemorrhage remains controversial. Outcomes in published studies are conflicting. A published meta-analysis of studies suggested some promise for early surgical intervention. However, a recent study comparing early surgery versus initial conservative treatment failed to demonstrate a benefit with surgery.

However, surgical intervention for cerebellar hematoma has been shown to improve outcome. It can be lifesaving in the prevention of brainstem compression.

Complications:
Increased intracranial pressure and herniation are the most dreaded complications. Worsening cerebral edema is often implicated in neurologic deterioration in the first 24-48 hours.Expansion of the hematoma is the most common cause of neurologic deterioration in the first 3 hours. In patients who are initially alert, 25% will have a decrease in consciousness within the first 24 hours. Post-stroke seizures may also develop as a complication.

Prognosis:
The prognosis varies depending on the severity of stroke and the location and the size of the hemorrhage. Lower Glasgow coma scores are associated with poorer prognosis and higher mortality. A larger volume of blood is associated with a poorer prognosis. The presence of blood in the ventricles is associated with a higher mortality rate. Other complicating medical comorbidities also affect the prognosis.

Medical/Legal Concerns:
The outcome generally follows the natural progression of the intracranial hemorrhage. Notwithstanding this, excellent and timely supportive management can often save the patient. Failure to act aggressively and a timely manner often results in an adverse outcome which then might lead to litigation.

Improper management of the patient's blood pressure can also have a deleterious effect on the patient. Failure to call in a neurologist and neurosurgeon often leads to a delay in the proper management of these patients.

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Thank you for your time,


Attorney & Physician Advisory Board
AMFS, Inc.
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