Our topic now moves into
Under hemorrhagic stroke,
How did this occur?
Was there hypertension,
You’ve heard of berry aneurysm.
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.
Well, no exception here.
And say that your patient has hypertension
and you have a berry aneurysm
in the anterior portion
of the circle of Willis.
Maybe the anterior communicating artery.
May result in
For example, metastatic lesions.
You could have choriocarcinoma.
Extremely common in terms
of where it metastasizes.
So for example, you find your patient
to have beta hCG to be elevated,
choriocarcinoma, gestational and
could be up to the brain.
Melanoma to the brain.
Thyroid cancer to the brain.
Lung to the brain.
Renal carcinoma to the brain.
This is a beautiful list of differentials.
that commonly, commonly,
may have brain metastasis
resulting in what?
Hemorrhagic type of stroke.
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.
At risk for what?
Some of these, you’ll find overlap
with ischemic stroke as well.
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
It changes the complexion
of the stroke clinically,
but it could actually
be part of a continuum.
So keep that in mind.
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.
Why do I bring that up?
Because there could be that hypertension,
which once again may result
in that berry aneurysm.
And if that ruptures, oh my goodness,
we call this thunder clap, right?
It is the worst headache that your
patient has ever experienced.
And this of course, should be referring
to your subarachnoid hemorrhage.
Anything that’s causing
Now here, with
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.
Once again, if there’s
it may result in an
ischemic type of stroke.
But if there’s hypertension
and it existed long enough,
at some point in time, the
blood vessel may rupture.
50-60% of the time, it will be
in the basal ganglia region.
It could be thalamus, pons, cerebellum,
lobar, as you can see in the picture here.
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.
About 50 to 60% of the time, you could
have what’s known as a lacunar infarct.
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?
Contralateral motor type of issues, right?
Contralateral motor type of issue
associated with atherosclerosis
and a diastolic blood
pressure of greater than 110.
Keep that in mind.
Remember, it’s a continuum.
Where are you in that continuum, which
will then categorize what kind of stroke.
Hemorrhagic stroke treatment.
So at this point, you know
your patient is bleeding.
Obviously, tPA is absolutely
I laughed because that’s
just a silly statement
and you’re laughing with me because
you know how silly that is.
So you’re going to
You know that your PT/PTT
probably is elevated.
So why not try to give something
that slows things down?
As you don’t have as much hemorrhage
taking place and bleeding.
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.
Continuing our management
of hemorrhagic stroke.
Remember we’re trying to
control the bleeding.
Platelets for thrombocytopenia.
And you find your platelet count
less than 100- or 50,000,
you start doing everything in
your power to slow down bleeding.
You want to now address the dam that has
broken so that you stop the bleeding.
You need to control that blood pressure
regardless always, always, always.
Maybe labetalol would be the
drug of choice, non-specific.
With hemorrhagic stroke, remember some of
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.
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.
If it’s AV malformations, so here,
you’ve identified the cause
of the hemorrhagic stroke
by using cerebral angiography.
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.
The risk factors in summarization of your
hemorrhagic stroke are the following:
Hypertension, AV malformation.
You’ll notice that once again
as I’ve told you earlier,
there is overlap between a hemorrhagic
stroke and ischemic stroke.
Most of the time, it will be ischemic.
But there’s every
hemorrhagic stroke in
fact would take place.
blood pressure control.
Signs and symptoms here,
focal neurologic symptoms,
decreased level of consciousness.
Differential diagnosis, once
again, an ischemic stroke.
As I said, overlap.
Todd’s paralysis and maybe
perhaps metabolic derangement.
Acute and post acute
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.
Treatment, blood pressure control
as we talked about earlier.
Reverse coagulopathy such
as fresh frozen plasma.
You’re thinking about
platelet being replenished.
If your platelet count is
And treatment of