Hemorrhagic stroke

Hemorrhagic stroke

1. GEMORRAGIC
STROKE.
STROKE PREVENTION

2. HEMORRAGIC STROKE
Rupture of abnormal artery or Outbreak of blood in
microaneurism, bleeding into the subarachnoid space
the substance of the brain
and formation of hematoma
intracerebral or
intraventricular
hemorrhage (2/3)
subarachnoid
hemorrhage (1/3)

3. Intracerebral
hemorrhage

4. 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

5. 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

6. Rupture of abnormal artery ((in arterial in arterial
hypertension) –the most often etiology (60%) of hypertension) –the most often etiology (60%) of
intraceribral hemorrhage

7. 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

8. Localization of hematoma

9. Intraceribral hemorrhage with
rupture into the ventriculal system

10. 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)

11. Diagnosis of intracerebral hemorrhage
CT-scan
 MR-angiography or contrast cerebral
аngiography to identify a possible aneurysm or
arteriovenous malformation
Later MRI

12. Right parietal hemorrhage Right parietal hemorrhage ((CTCT))

13. Hemorrhage into basal ganglia Hemorrhage into basal ganglia
and thalamus and thalamus (М(МRIRI))

14. Intraventriculal hemorrhageIntraventriculal hemorrhage

15. Intracerebral hemorrhage in different periodsIntracerebral hemorrhage in different periods
1 1 dayday
7 7 daysdays 16 16 daysdays

16. Arteriovenous malformation
CТMR-аngiography
MRI

17. 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

18. SUBARACHNOID
HEMORRHAGE

19. ETIOLOGY OF
SUBARACHNOID HEMORRHAGE
•Rupture of aneurysm (in 60-
70% сases)
- saccular aneurysm
- arteriovenous malformation
Rare:
complication in treatment
with anticoagulants,
thrombolytics
Hematological disorders
Unknown etiology

20. ETIOLOGY OF
SUBARACHNOID 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

21. Localization of saccular aneurysmLocalization of saccular aneurysm

22. Accumulation of blood in
subarachnoid space results in
severe headache

23. 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

24. Diagnosis of subarachnoid
hemorrhage
CT scan
Lumbar puncture
MR-angiography or contrast cerebral
аngiography

25. CT AND МRI IN SUBARACHNOID HEMORRAGE

26. Lumbar puncture
The presence of blood in CSF

27. Contrast аngiography
Saccular аneurysm in blood vessels

28. 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

29. Vasospasm and cerebral ischemia in
subarachnoid hemorrhage

30. 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

31. Indications for surgical treatment in
intracerebral hemorrhage
•Large (>40 ml) and
superficial hematoma
with brain compression
signs
•Acute hydrocephaly
•Large hematoma in
cerebellum

32. TREATMENT OF SUBARACHNOID
HEMORRHAGE
Strict bed regimen
Surgical treatment (in presence of aneurism)
Ca-antagonists (nimodopin) - prevention for
secondary vasospasm
Monitoring of BP, ECG, blood glucose,
electrolytes
Analgetics (in severe headache)

33. Coil Embolization

34. Aneurysm clipping

35. COMPLICATIONS OF
SUBARACHNOID HEMORRHAGE
Cerebral vasospasm (possible ischemic stroke)
Recurrent subarachnoid hemorrhage
Brain edema and hydrocephaly

36. SECONDARY
STROKE
PREVENTION

37. RISK FACTORS FOR ISCEMIC STROKE
Arterial hypertension
(>140mmHg systolic, >90mmHg diastolic)
Heart diseases (atrial fibrillation)
Stenosis of corotid artery (>70%)
Hyperlipidemia
Diabetes 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

38. 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

39. Carotid endarterectomy

40. Carotid stenting