GEMORRAGIC STROKE. STROKE PREVENTION
GEMORRAGIC STROKE.
STROKE PREVENTION
HEMORRAGIC STROKE
Rupture of abnormal artery or Outbreak of blood in microaneurism, bleeding into the subarachnoid space the substance of the brainand formation of hematoma
intracerebral or intraventricular hemorrhage (2/3)
subarachnoid hemorrhage (1/3)
Intracerebral hemorrhage
Epidemiology of intracerebral hemorrhage
ICH is the second most common cause of stroke,
accounting for 10% to 15% of all strokes.
ICH has significantly higher mortality risks, with 30-
day mortality estimates ranging from 35% to 52%, a
rate approximately 5 times greater than the mortality
for ischemic stroke
Etiology of intracerebral hemorrhage
Primary (hypertensive) intracerebral hemorrhage
Ruptured saccular aneurysm, AVM, venous and dural vascular malformations
Brain trauma
Hemorrhagic disorders: leukemia, aplastic anemia, thrombocytopenic purpura,
complication of anticoagulant r thrombolytic therapy, hypofibrinogenemia,
hemophilia
Hemorrhage into primary and secondary brain tumors
Alcocholic disease, narcotic overdose
Amyloid angiopathy
Rupture of abnormal artery ((in arterial in arterial hypertension) –the most often etiology (60%) of hypertension) –the most often etiology (60%) of
intraceribral hemorrhage
Pathophysiology of hemorrachic stroke
Acute hydrocephaly
Increased intracranial pressure
Brain edema
Dislocation of brain structures Brainstem compression
Haematoma resolution occurs in 4-8 weeks, leaving a cystic
cavity
Localization of hematoma
Intraceribral hemorrhage with rupture into the ventriculal system
Clinical signs and symptoms of intracerebral hemorrhage
Acute onset with local signs, according to the location and size of the hematoma (hemiparesis, hemihypoesthesia, cerebellar syndrome)
Diffuse neurologic signs (headache, nausea/vomiting),
Loss of consciousness (in small hematoma may be absent)
Meningeal syndrome (in small hematoma may be absent)
Diagnosis of intracerebral hemorrhage
CT-scan MR-angiography or contrast cerebral
аngiography to identify a possible aneurysm or arteriovenous malformation
Later MRI
Right parietal hemorrhage Right parietal hemorrhage ((CTCT))
Hemorrhage into basal ganglia Hemorrhage into basal ganglia and thalamus and thalamus (М(МRIRI))
Intraventriculal hemorrhageIntraventriculal hemorrhage
Intracerebral hemorrhage in different periodsIntracerebral hemorrhage in different periods
1 1 dayday 7 7 daysdays 16 16 daysdays
Arteriovenous malformation
CТMR-аngiography
MRI
PROGNOSIS OF INTRACEREBRAL HEMORRHAGE
Poor prognostic features Large, deep lesions Depth of conscious level (flexion or extension to
painful stimuli)
Good prognostic features Small superficial hematoma
Conscious patients
The overall mortality ranges from 55-65%, 90% if the patient is in coma
SUBARACHNOID
HEMORRHAGE
ETIOLOGY OFSUBARACHNOID HEMORRHAGE
• Rupture of aneurysm (in 60-70% сases)
- saccular aneurysm - arteriovenous malformation Rare: complication in treatment
with anticoagulants, thrombolytics
Hematological disorders Unknown etiology
ETIOLOGY OFSUBARACHNOID HEMORRHAGE
Intracranial aneurysms are abnormal focal dilatations of the cerebral arteries, with thinning and weakening of the vessel wall
AVM is an aggregate of arterial and venous communications with no intervening capillary network
Localization of saccular aneurysmLocalization of saccular aneurysm
Accumulation of blood in subarachnoid space results in
severe headache
Clinical signs and symptoms of subarachnoid hemorrhage
Severe (“thunderclap”) headache
Loss of consciousness
Meningeal syndrome (neck stiffness, Kernig’s sign,
nausea, vomiting, photophobia)
Epileptic seizure
Psychomotor excitation
“Reactive hypertension”, hyperthermia, tachycardia
Diagnosis of subarachnoid hemorrhage
CT scanLumbar punctureMR-angiography or contrast cerebral
аngiography
CT AND МRI IN SUBARACHNOID HEMORRAGE
Lumbar puncture
The presence of blood in CSF
Contrast аngiographySaccular аneurysm in blood vessels
Prognosis of subarachnoid hemorrhage
High fatality, ranging from 30% to 70% and depend on the severity of the initial presentation
Among those who survive, early rebreeding and delayed ischemic neurologic deficits from vasospasm can cause serious mortality
Vasospasm and cerebral ischemia in subarachnoid hemorrhage
PRINCIPLES OF INTRACEREBRAL AND SUBARACHNOID HEMORRHAGE TREATMENT
Surgical treatment
In cerebral hemorrhage – removal of hematoma
In subarachnoid hemorrhage – clipping the aneurysm
Monitoring of BP, ECG, blood glucose, electrolytes
Prevention and treatment of complications Rehabilitation
Indications for surgical treatment in intracerebral hemorrhage
• Large (>40 ml) and superficial hematoma with brain compression signs
• Acute hydrocephaly• Large hematoma in
cerebellum
TREATMENT OF SUBARACHNOID HEMORRHAGE
Strict bed regimenSurgical treatment (in presence of aneurism)Ca-antagonists (nimodopin) - prevention for
secondary vasospasmMonitoring of BP, ECG, blood glucose,
electrolytesAnalgetics (in severe headache)
Coil Embolization
Aneurysm clipping
COMPLICATIONS OF SUBARACHNOID HEMORRHAGE
Cerebral vasospasm (possible ischemic stroke)
Recurrent subarachnoid hemorrhage
Brain edema and hydrocephaly
SECONDARY STROKE
PREVENTION
RISK FACTORS FOR ISCEMIC STROKE
Arterial hypertension (>140mmHg systolic, >90mmHg diastolic)
Heart diseases (atrial fibrillation)
Stenosis of corotid artery (>70%)
HyperlipidemiaDiabetes mellitus
Cigarette smoking Alcohol abuse (>60 g of alcohol or 75 cl of wine per day in men, >40 g in women)
Low physical activity
Peripheral artery diseases
SECONDARY STROKE PREVENTION • Blood pressure control • Normal life-style (no smoking, no drinking)
After ischemic stroke:1. Atherotrombotic type
- antiplatelet agent, including aspirin, 50 to 325 mg/d; the combination of aspirin, 25 mg, plus extended-release dipyridamole, 200 mg, twice daily; and clopidogrel, 75 mg/d. Clopidogrel is a reasonable alternative in patients allergic to aspirin.
- statins - surgical treatment (carotid endarterectomy, stinting)
2. Cardioembolic type - anticoagulants: varpharin
Carotid endarterectomy
Carotid stenting