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Hemorrhagic Stroke

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Hemorrhagic Stroke Hemorrhagic strokes account for 15% to 20% of cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage. – PowerPoint PPT presentation

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Title: Hemorrhagic Stroke


1
Hemorrhagic Stroke
  • Hemorrhagic strokes account for 15 to 20 of
    cerebrovascular disorders and are primarily
    caused by intracranial or subarachnoid hemorrhage.

2
  • Hemorrhagic strokes are caused by bleeding into
    the brain tissue, the ventricles, or the
    subarachnoid space.
  • Primary intracerebral hemorrhage from a
    spontaneous rupture of small vessels accounts for
    approximately 80 of hemorrhagic strokes and is
    caused chiefly by uncontrolled hypertension.
  • Subarachnoid hemorrhage results from a ruptured
    intracranial aneurysm (a weakening in the
    arterial wall) in about half the cases

3
  • Another common cause of intracerebral hemorrhage
    in the elderly is cerebral amyloid angiopathy,
    which involves damage caused by the deposit of
    beta-amyloid protein in the small and
    medium-sized blood vessels of the brain.
  • Secondary intracerebral hemorrhage is associated
    with arteriovenous malformations (AVMs),
    intracranial aneurysms, intracranial neoplasms,
    or certain medications (eg, anticoagulants,
    amphetamines).

4
  • The mortality rate has been reported to be as
    high as 43 at 30 days after an intracranial
    hemorrhage . Patients who survive the acute phase
    of care usually have more severe deficits and a
    longer recovery time compared to those with
    ischemic stroke.

5
Pathophysiology
  • The pathophysiology of hemorrhagic stroke depends
    on the cause and type of cerebrovascular
    disorder. Symptoms are produced when a primary
    hemorrhage, aneurysm, or AVM presses on nearby
    cranial nerves or brain tissue or, more
    dramatically, when an aneurysm or AVM ruptures,
    causing subarachnoid hemorrhage

6
  • (hemorrhage into the cranial subarachnoid space).
    Normal brain metabolism is disrupted by the
    brain's being exposed to blood by an increase in
    ICP resulting from the sudden entry of blood into
    the subarachnoid space, which compresses and
    injures brain tissue or by secondary ischemia of
    the brain resulting from the reduced perfusion
    pressure and vasospasm that frequently accompany
    subarachnoid hemorrhage.

7
Intracerebral Hemorrhage
  • An intracerebral hemorrhage, or bleeding into the
    brain substance, is most common in patients with
    hypertension and cerebral atherosclerosis,
    because degenerative changes from these diseases
    cause rupture of the blood vessel. An
    intracerebral hemorrhage may also result from
    certain types of arterial pathology, brain
    tumors, and the use of medications (oral
    anticoagulants, amphetamines, and illicit drug
    use).
  • Bleeding occurs most commonly in the cerebral
    lobes, basal ganglia, thalamus, brain stem
    (mostly the pons), and cerebellum. Occasionally,
    the bleeding ruptures the wall of the lateral
    ventricle and causes intraventricular hemorrhage,
    which is frequently fatal.

8
Intracranial (Cerebral) Aneurysm
  • An intracranial (cerebral) aneurysm is a dilation
    of the walls of a cerebral artery that develops
    as a result of weakness in the arterial wall. The
    cause of aneurysms is unknown, although research
    is ongoing. An aneurysm may be due to
    atherosclerosis, which results in a defect in the
    vessel wall with subsequent weakness of the wall
    a congenital defect of the vessel wall
    hypertensive vascular disease head trauma or
    advancing age.
  • The cerebral arteries most commonly affected by
    an aneurysm are the internal carotid artery
    (ICA), anterior cerebral artery (ACA), anterior
    communicating artery (ACoA), posterior
    communicating artery (PCoA), posterior cerebral
    artery (PCA), and middle cerebral artery (MCA).
    Multiple cerebral aneurysms are not uncommon.

9
Arteriovenous Malformations
  • An AVM is caused by an abnormality in embryonal
    development that leads to a tangle of arteries
    and veins in the brain that lacks a capillary
    bed. The absence of a capillary bed leads to
    dilation of the arteries and veins and eventual
    rupture. AVM is a common cause of hemorrhagic
    stroke in young people.

10
Subarachnoid Hemorrhage
  • A subarachnoid hemorrhage (hemorrhage into the
    subarachnoid space) may occur as a result of an
    AVM, intracranial aneurysm, trauma, or
    hypertension. The most common causes are a
    leaking aneurysm in the area of the circle of
    Willis and a congenital AVM of the brain.

11
Clinical Manifestations
  • The patient with a hemorrhagic stroke can present
    with a wide variety of neurologic deficits,
    similar to the patient with ischemic stroke.
  • The conscious patient most commonly reports a
    severe headache
  • Many of the same motor, sensory, cranial nerve,
    cognitive, and other functions that are disrupted
    after ischemic stroke are also altered after a
    hemorrhagic stroke. Other symptoms that may be
    observed more frequently in patients with acute
    intracerebral hemorrhage (compared with ischemic
    stroke) are vomiting, an early sudden change in
    level of consciousness, and possibly focal
    seizures due to frequent brain stem involvement .

12
Clinical Manifestations
  • Rupture of an aneurysm or AVM usually produces a
    sudden, unusually severe headache and often loss
    of consciousness for a variable period of time.
    There may be pain and rigidity of the back of the
    neck (nuchal rigidity) and spine due to meningeal
    irritation. Visual disturbances (visual loss,
    diplopia, ptosis) occur if the aneurysm is
    adjacent to the oculomotor nerve. Tinnitus,
    dizziness, and hemiparesis may also occur.
  • In other cases, severe bleeding occurs, resulting
    in cerebral damage, followed rapidly by coma and
    death.

13
Assessment and Diagnostic Findings
  • Any patient with suspected stroke should undergo
    a CT scan to determine the type of stroke, the
    size and location of the hematoma, and the
    presence or absence of ventricular blood and
    hydrocephalus.
  • CT scan and cerebral angiography confirm the
    diagnosis of an intracranial aneurysm or AVM.
    These tests show the location and size of the
    lesion and provide information about the affected
    arteries, veins, adjoining vessels, and vascular
    branches.
  • Lumbar puncture is performed if there is no
    evidence of increased ICP, the CT scan results
    are negative, and subarachnoid hemorrhage must be
    confirmed. Lumbar puncture in the presence of
    increased ICP could result in brain stem
    herniation or rebleeding.
  • When diagnosing a hemorrhagic stroke in a patient
    younger than 40 years of age, some clinicians
    obtain a toxicology screen for illicit drug use.

14
Prevention
  • Primary prevention of hemorrhagic stroke is the
    best approach and includes managing hypertension
    and ameliorating other significant risk factors.
  • Control of hypertension, especially in people
    older than 55 years of age, clearly reduces the
    risk for hemorrhagic stroke. Additional risk
    factors are increased age, male gender, and
    excessive alcohol intake).
  • A prevention effort unique to hemorrhagic stroke
    is to increase the public's awareness about the
    association between phenylpropanolamine (PPA, an
    ingredient found in appetite suppressants as well
    as cold and cough agents) and hemorrhagic stroke.

15
Complications
  • Potential complications of hemorrhagic stroke
    include rebleeding cerebral vasospasm resulting
    in cerebral ischemia acute hydrocephalus, which
    results when free blood obstructs the
    reabsorption of cerebrospinal fluid (CSF) by the
    arachnoid villi and seizures.

16
Cerebral Hypoxia and Decreased Blood Flow
  • Immediate complications of a hemorrhagic stroke
    include cerebral hypoxia, decreased cerebral
    blood flow, and extension of the area of injury.
    Providing adequate oxygenation of blood to the
    brain minimizes cerebral hypoxia. Brain function
    depends on delivery of oxygen to the tissues.
    Administering
  • supplemental oxygen and maintaining the
    hemoglobin and hematocrit at acceptable levels
    will assist in maintaining tissue oxygenation.
  • Cerebral blood flow is dependent on the blood
    pressure, cardiac output, and integrity of
    cerebral blood vessels. Adequate hydration (IV
    fluids) must be ensured to reduce blood viscosity
    and improve cerebral blood flow. Extremes of
    hypertension or hypotension need to be avoided to
    prevent changes in cerebral blood flow and the
    potential for extending the area of injury.
  • A seizure can also compromise cerebral blood
    flow, resulting in further injury to the brain.
    Observing for seizure activity and initiating
    appropriate treatment are important components of
    care after a hemorrhagic stroke.

17
Vasospasm
  • The development of cerebral vasospasm (narrowing
    of the lumen of the involved cranial blood
    vessel. The mechanism responsible for the spasm
    is not clear, but vasospasm is associated with
    increasing amounts of blood in the subarachnoid
    cisterns and cerebral fissures, as visualized by
    CT scan. Monitoring for vasospasm may be
    performed through the use of bedside transcranial
    Doppler ultrasonography (TCD) or follow-up
    cerebral angiography).
  • Vasospasm leads to increased vascular resistance,
    which impedes cerebral blood flow and causes
    brain ischemia and infarction. The signs and
    symptoms reflect the areas of the brain involved.
    Vasospasm is often heralded by a worsening
    headache, a decrease in level of consciousness
    (confusion, lethargy, and disorientation), or a
    new focal neurologic deficit (aphasia,
    hemiparesis).

18
Increased ICP
  • An increase in ICP can occur after either an
    ischemic or a hemorrhagic stroke but almost
    always follows a subarachnoid hemorrhage, usually
    because of disturbed circulation of CSF caused by
    blood in the basal cisterns. If the patient shows
    evidence of deterioration from increased ICP (due
    to cerebral edema, herniation, hydrocephalus, or
    vasospasm).

19
Systemic Hypertension
  • Preventing sudden systemic hypertension is
    critical in the management of intracerebral
    hemorrhage. Although specific goals for blood
    pressure management are individualized for each
    patient, systolic blood pressure may be lowered
    to less than 150 mm Hg to prevent hematoma
    enlargement . If blood pressure is elevated,
    antihypertensive therapy .

20
Medical Management
  • The goals of medical treatment for hemorrhagic
    stroke are to allow the brain to recover from the
    initial insult (bleeding), to prevent or minimize
    the risk for rebleeding, and to prevent or treat
    complications.
  • Management is primarily supportive and consists
    of bed rest with sedation to prevent agitation
    and stress, management of vasospasm, and surgical
    or medical treatment to prevent rebleeding.
    Analgesics (codeine, acetaminophen) may be
    prescribed for head and neck pain. The patient is
    fitted with sequential compression devices to
    prevent deep vein thrombosis (DVT) .

21
Surgical Management
  • In many cases, a primary intracerebral hemorrhage
    is not treated surgically. However, if the
    diameter of the hematoma exceeds 3 cm and the
    Glasgow Coma Scale score decreases,
  • .surgical evacuation is strongly recommended for
    the patient with a cerebellar hemorrhage.
    Surgical evacuation is most frequently
    accomplished via a craniotomy .
  • The patient with an intracranial aneurysm is
    prepared for surgical intervention as soon as his
    or her condition is considered stable.
  • Morbidity and mortality from surgery are high if
    the patient is stuporous or comatose (Hunt-Hess
    grade 4 or 5). Surgical treatment of the patient
    with an unruptured aneurysm is an option.

22
Surgical Management
  • The goal of surgery is to prevent bleeding in an
    unruptured aneurysm or further bleeding in an
    already ruptured aneurysm. This objective is
    accomplished by isolating the aneurysm from its
    circulation or by strengthening the arterial
    wall. An aneurysm may be excluded from the
    cerebral circulation by means of a ligature or a
    clip across its neck. If this is not anatomically
    possible, the aneurysm can be reinforced by
    wrapping it with some substance to provide
    support and induce scarring.
  • Several less invasive endovascular treatments are
    now being used for aneurysms. These procedures
    are performed by neurosurgeons in
    neurointerventional radiology facilities. Two
    procedures are endovascular treatment (occlusion
    of the parent artery) and aneurysm coiling
    (obstruction of the aneurysm site with a coil).
    Although these techniques are associated with
    lower risks than intracranial surgery in general,
    secondary stroke and rupture of the aneurysm are
    still potential complications

23
Nursing ProcessThe Patient With a Hemorrhagic
Stroke
  • Assessment
  • A complete neurologic assessment is performed
    initially and includes evaluation for the
    following

24
  • Altered level of consciousness
  • Sluggish pupillary reaction
  • Motor and sensory dysfunction
  • Cranial nerve deficits (extraocular eye
    movements, facial droop, presence of ptosis)
  • Speech difficulties and visual disturbance
  • Headache and nuchal rigidity or other neurologic
    deficits

25
DiagnosisNursing Diagnoses
  • Based on the assessment data, the patient's major
    nursing diagnoses may include the following
  • Ineffective tissue perfusion (cerebral) related
    to bleeding or vasospasm
  • Disturbed sensory perception related to medically
    imposed restrictions (aneurysm precautions)
  • Anxiety related to illness and/or medically
    imposed restrictions (aneurysm precautions)

26
Collaborative Problems/Potential Complications
  • Based on the assessment data, potential
    complications that may develop include the
    following
  • Vasospasm
  • Seizures
  • Hydrocephalus
  • Rebleeding
  • Hyponatremia

27
Planning and Goals
  • The goals for the patient may include improved
    cerebral tissue perfusion, relief of sensory and
    perceptual deprivation, relief of anxiety, and
    the absence of complications.

28
  • Nursing Interventions
  • Optimizing Cerebral Tissue Perfusion
  • Implementing Aneurysm Precautions
  • Cerebral aneurysm precautions are implemented for
    the patient with a diagnosis of aneurysm to
    provide a nonstimulating environment, prevent
    increases in ICP, and prevent further bleeding.
  • Relieving Sensory Deprivation and Anxiety
  • Sensory stimulation is kept to a minimum for
    patients on aneurysm precautions. For patients
    who are awake, alert, and oriented, an
    explanation of the restrictions helps reduce the
    patient's sense of isolation. Reality orientation
    is provided to help maintain orientation.

29
  • Monitoring and Managing Potential Complications
  • Vasospasm
  • Seizures
  • Hydrocephalus
  • Blood in the subarachnoid space or ventricles
    impedes the circulation of CSF, resulting in
    hydrocephalus. A CT scan that indicates dilated
    ventricles confirms the diagnosis. Hydrocephalus
    can occur within the first 24 hours (acute) after
    subarachnoid hemorrhage or several days
    (subacute) to several weeks (delayed) later.
    Symptoms vary according to the time of onset and
    may be nonspecific. Acute hydrocephalus is
    characterized by sudden onset of stupor or coma
    and is managed with a ventriculostomy drain to
    decrease ICP

30
  • Rebleeding
  • The rate of recurrent hemorrhage is approximately
    2 after a primary intracerebral hemorrhage.
    Hypertension is the most serious risk factor,
    suggesting the importance of appropriate
    antihypertensive treatment .
  • Hyponatremia
  • After subarachnoid hemorrhage, hyponatremia is
    found in 10 to 40 of patients.Laboratory data
    must be checked frequently, and hyponatremia
    (defined as a serum sodium concentration of less
    than 135 mEq/L) must be identified as early as
    possible. The physician needs to be notified of a
    low serum sodium level that has persisted for 24
    hours or longer

31
  • Promoting Home and Community-Based Care
  • Teaching Patients Self-Care
  • Continuing Care
  • Evaluation
  • Expected Patient Outcomes

32
  • Expected patient outcomes may include the
    following
  • Demonstrates intact neurologic status and normal
    vital signs and respiratory patterns
  • Is alert and oriented to time, place, and person
  • Demonstrates normal speech patterns and intact
    cognitive processes
  • Demonstrates normal and equal strength, movement,
    and sensation of all four extremities
  • Exhibits normal deep tendon reflexes and
    pupillary responses
  • Demonstrates normal sensory perceptions
  • States rationale for aneurysm precautions
  • Exhibits clear thought processes
  • Exhibits reduced anxiety level
  • Is less restless
  • Exhibits absence of physiologic indicators of
    anxiety (eg, has normal vital signs normal
    respiratory rate absence of excessive, fast
    speech)

33
  • Is free of complications
  • Exhibits absence of vasospasm
  • Exhibits normal vital signs and neuromuscular
    activity without seizures
  • Verbalizes understanding of seizure precautions
  • Exhibits normal mental status and normal motor
    and sensory status
  • Reports no visual changes

34
Critical Thinking Exercises
  • Your patient had symptoms of an ischemic stroke
    approximately 1 hour ago and is undergoing a
    confirmatory CT scan in 30 minutes. What are the
    time frame and criteria for t-PA administration?
    What nursing actions would you take? What is your
    rationale for these actions?
  • Your patient has expressive aphasia following an
    ischemic stroke. How would you explain this
    phenomenon to the patient and family? Describe
    appropriate techniques for communicating with a
    patient with this type of aphasia.
  • Your patient is admitted with hemorrhagic stroke
    and is at high risk for DVT. What measures should
    be implemented for DVT prophylaxis? Identify the
    evidence for and the criteria used to evaluate
    the strength of the evidence for the specific
    measures identified for DVT prophylaxis.
  • A 70-year-old patient with a history of diabetes
    is expected to be discharged to home today after
    a 5-day stay for an ischemic stroke. She has some
    residual right-sided weakness. What teaching
    would be indicated to prevent another stroke?
    What resources may be needed to enable her to go
    home as scheduled?
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