Raising Awareness of Hemorrhagic Stroke By Kelly A

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 ¡ 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 ¡ 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 ¡ Cardiac enzymes and troponin ¡ Blood urea nitrogen ¡ Creatinine ¡ Serum blood glucose ¡ Prothrombin time, INR, partial thromboplastin time ¡ Oxygen saturation • ¡ ¡ ¡ ECG Complete blood cell count, including platelets Electrolytes

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 ¡ ¡ Minimize external stimuli ¡ Control of blood glucose levels ¡ ICP and BP will be managed ¡ Seizure management (as recommended by the AHA) Analgesics for head and neck pain

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 ¡ Speech and vision difficulties ¡ Sluggish pupillary reaction ¡ Headache, nuchal rigidity, other neurologic deficits ¡ Vital sign changes, including an increase or drop in ICP, BP, or heart rate ¡ ¡ Motor and sensory dysfunction Cranial nerve deficits

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