Hemorrhagic Stroke

00:01 Our topic now moves into hemorrhagic stroke.

00:05 Under hemorrhagic stroke, intracerebral hemorrhage.

00:09 How did this occur? Was there hypertension, for example You’ve heard of berry aneurysm.

00:14 Whenever you hear about aneurysm, what are you worried about? With an aneurysm, you’re worried about enough of expansion taking place where a rupture may take place, resulting in a type of hemorrhage.

00:25 Well, no exception here.

00:27 And say that your patient has hypertension and you have a berry aneurysm in the anterior portion of the circle of Willis.

00:33 Maybe the anterior communicating artery.

00:35 May result in intracerebral hemorrhage.

00:37 Mass lesions.

00:39 For example, metastatic lesions.

00:41 You could have choriocarcinoma.

00:43 Extremely common in terms of where it metastasizes.

00:49 So for example, you find your patient to have beta hCG to be elevated, choriocarcinoma, gestational and non-gestational choriocarcinoma.

00:58 Metastasis unfortunately could be up to the brain.

01:02 Melanoma to the brain.

01:04 Thyroid cancer to the brain.

01:06 Lung to the brain.

01:08 Renal carcinoma to the brain.

01:10 This is a beautiful list of differentials.

01:13 Cancer differentials that commonly, commonly, may have brain metastasis resulting in what? Hemorrhagic type of stroke.

01:24 Vascular malformations Amyloid angiopathy.

01:29 Usually, when you hear about amyloid especially up in the brain, you should be thinking about your Alzheimer’s and some of that amyloid, when it starts accumulating in your blood vessel, you call this amyloid angiopathy.

01:40 At risk for what? Hemorrhagic stroke.

01:44 Cocaine/amphetamine use.

01:46 Some of these, you’ll find overlap with ischemic stroke as well.

01:51 Remember it’s a little fine line, isn’t it? Between an ischemic stroke and then if the blood vessel in fact does rupture, may result in hemorrhagic stroke.

02:01 It changes the complexion of the stroke clinically, but it could actually be part of a continuum.

02:08 So keep that in mind.

02:09 Don’t be so black and white that you think, “Oh, it only must be this.” Where are you in terms of your timeline? And how did it then manifest? Maybe your patient has autosomal dominant polycystic kidney disease.

02:23 Why do I bring that up? Because there could be that hypertension, which once again may result in that berry aneurysm.

02:29 And if that ruptures, oh my goodness, we call this thunder clap, right? It is the worst headache that your patient has ever experienced.

02:37 And this of course, should be referring to your subarachnoid hemorrhage.

02:41 Trauma.

02:43 Anything that’s causing subarachnoid hemorrhage.

02:48 Now here, with hypertensive hemorrhage.

02:51 So this time, what we’ll do is we’ll take a look at blood vessel that ruptures, but it was hypertension that existed prior.

02:59 Once again, if there’s hypertension, remember, it may result in an ischemic type of stroke.

03:07 But if there’s hypertension and it existed long enough, at some point in time, the blood vessel may rupture.

03:15 50-60% of the time, it will be in the basal ganglia region.

03:19 It could be thalamus, pons, cerebellum, lobar, as you can see in the picture here.

03:24 I’ve highlighted for the different areas of the brain in which the hemorrhage may take place, which then from neuroanatomy, you will know as to how the patient is going to present.

03:35 About 50 to 60% of the time, you could have what’s known as a lacunar infarct.

03:40 What does lacunar infarct mean to you? The penetrating deep blood vessels that are rather tiny in which an aneurysm that then ruptures, may result in a hemorrhagic type of stroke, resulting in what kind of issues in your patient? Good.

03:54 Contralateral motor type of issues, right? Contralateral motor type of issue associated with atherosclerosis and a diastolic blood pressure of greater than 110.

04:04 Keep that in mind.

04:05 Remember, it’s a continuum.

04:07 Where are you in that continuum, which will then categorize what kind of stroke.

04:13 Hemorrhagic stroke treatment.

04:15 Reverse coagulopathy.

04:17 So at this point, you know your patient is bleeding.

04:19 Obviously, tPA is absolutely contraindicated, right? I laughed because that’s just a silly statement and you’re laughing with me because you know how silly that is.

04:29 So you’re going to avoid anticoagulation.

04:32 You know that your PT/PTT probably is elevated.

04:37 So why not try to give something that slows things down? As you don’t have as much hemorrhage taking place and bleeding.

04:45 Why not replenish some of those coagulation factors? Welcome to fresh frozen plasma, huh? What does plasma mean to you? It means that you’re doing what? Replenishing the coagulation factors so that you can address -- what are you’re looking at? The elevated PT/PTT.

05:02 Continuing our management of hemorrhagic stroke.

05:05 Remember we’re trying to control the bleeding.

05:07 Platelets for thrombocytopenia.

05:09 And you find your platelet count less than 100- or 50,000, you start doing everything in your power to slow down bleeding.

05:15 You want to now address the dam that has broken so that you stop the bleeding.

05:21 You need to control that blood pressure regardless always, always, always.

05:24 Maybe labetalol would be the drug of choice, non-specific.

05:29 With hemorrhagic stroke, remember some of the causes could be the list of cancers that I’ve given you such as your melanoma or your choriocarcinoma, renal cell, lung cancers It might metastasize to the brain resulting in intracerebral type of hemorrhage.

05:44 Well, what if that was the cause of the hemorrhagic stroke? Why not identify it and see as to what you want to do next? Do you wish to then go into surgery? So on and so forth.

05:54 If it’s AV malformations, so here, you’ve identified the cause of the hemorrhagic stroke by using cerebral angiography.

06:03 This is then showing you that there is an AV malformation And at that point, appropriate steps in terms of surgery can then be taken.

06:12 The risk factors in summarization of your hemorrhagic stroke are the following: Hypertension, AV malformation.

06:19 You’ll notice that once again as I’ve told you earlier, there is overlap between a hemorrhagic stroke and ischemic stroke.

06:26 Most of the time, it will be ischemic.

06:29 But there’s every possibility that hemorrhagic stroke in fact would take place.

06:34 Metastatic tumors.

06:35 Preventive medicine, blood pressure control.

06:37 Signs and symptoms here, focal neurologic symptoms, decreased level of consciousness.

06:43 Differential diagnosis, once again, an ischemic stroke.

06:47 As I said, overlap.

06:48 Todd’s paralysis and maybe perhaps metabolic derangement.

06:54 Acute and post acute diagnostic workup.

06:57 What are you trying to do here? Why don’t you try to identify that hemorrhage, huh? MRI to evaluate the underlying lesion, sometimes we’ll repeat in six weeks when blood products resolve.

07:11 Treatment, blood pressure control as we talked about earlier.

07:14 Reverse coagulopathy such as fresh frozen plasma.

07:18 You’re thinking about platelet being replenished.

07:21 If your platelet count is decreased, thrombocytopenia.

07:24 And treatment of underlying lesion.