Recognizing hemorrhagic strokes

In this video, we look at the process to use when trying to distinguish between ischemic vs hemorrhagic stroke, risk factors for each, and why surgery is often not indicated in hemorrhagic stroke.

Gary R. Simonds, MD MHCDS FAANS
Gary R. Simonds, MD MHCDS FAANS
10th Sep 2021 • 4m read

When a patient presents with sudden-onset, severe neurological deficits, it can be super difficult to distinguish an ischemic stroke from a hemorrhagic stroke. So how do you recognize a hemorrhagic stroke and what can be done about it? In this video, we look at the process to use when trying to distinguish between them, the risk factors for each, and why surgery is often not indicated in hemorrhagic stroke.

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Video transcript

Let's take a moment and discuss how an ischemic stroke differs from a hemorrhagic stroke. Ischemic strokes occur when the blood flow and oxygen delivery to an area of the brain drops to a level that leads to neuronal death in that region. A hemorrhagic stroke is a broad based term for any type of spontaneous, intracranial hemorrhage in or around the brain tissue.

It may occur in the bed of an ischemic stroke, but can be totally unrelated to a classic ischemic stroke. There are actually a wide variety of pathological entities that can lead to a spontaneous intracranial hemorrhage, or hemorrhagic stroke. Many lead to emergent intervention, so let's discuss them and their emergent management.

Spontaneous intracranial hemorrhages can occur within the brain, called an interest cerebral hemorrhage, or an intra parenchymal hemorrhage, or between the brain and the skull, called a subarachnoid hemorrhage, subdural hemorrhage or epidural hemorrhage. Spontaneous subarachnoid hemorrhage is usually secondary to an aneurysmal rupture, we'll cover that in a later chapter.

Subdural and epidural hemorrhages are usually due to trauma, and we'll cover those in another chapter. A spontaneous intracerebral hemorrhage becomes evident when intracranial bleeding abruptly raises intracranial pressure, causing sudden severe headache, vomiting, and or loss of consciousness or causes brain dysfunction by compressing or damaging adjacent brain tissue, resulting in what is known as focal deficits such as weakness, aphasia, loss of sensation, imbalance, etc.

Such hemorrhages can occur without warning, at rest, or during activity. Clinically it can be difficult to distinguish an ischemic stroke from a hemorrhagic stroke. Classically, the patient may sustained a severe headache with associated nausea and vomiting and progressive neurologic deficit, or they may simply collapse into coma.

But they may also present with isolated onset of new neurologic deficits, as seen with many ischemic strokes. In evaluating a patient for potential hemorrhagic stroke, always consider the patient's ABCs, support ventilation and resuscitate as necessary, then, obtain an expedited history and neurological exam, paying attention to conditions that are associated with a higher risk of hemorrhage, and of ischemic stroke.

Some things that increase the risk of spontaneous intra cerebral hemorrhage include high blood pressure, heavy alcohol use, clotting abnormalities, illicit drug use, such as cocaine and amphetamines. previous history of trauma, systemic infection, known cerebral vascular abnormalities, such as arteriovenous malformations or aneurisms, hormonal birth control use, pregnancy, congenital cardiac abnormalities, atrial fibrillation, anticoagulant use, previous intracranial hemorrhages or surgeries, atherosclerosis, cancer, and advanced age.

Furthermore, risk factors that predispose a patient to ischemic stroke also predispose them to hemorrhagic stroke. When evaluating the patient, be on the lookout for signs of increased intracranial pressure, and potential brain herniation. Initiate ICP control interventions, if concerned. Move to imaging as quickly as possible. Early imaging is important because hemorrhagic strokes have a tendency to progress. Therefore, it's best to know what you're dealing with as early as possible.

So as soon as the patient is stable enough, obtain a noncontrast CT scan of the brain. Remind yourself that hemorrhages can expand over the following day, particularly if blood pressure is not well controlled. Therefore, repeat the CT scan of the head eight to 24 hours after the first or if there is any deterioration in the patient's neurological status.

If an intracranial hemorrhage is found on imaging a CT angiogram should be performed after the initial CT, either immediately or with the follow up CT. This is used to evaluate for entities such as arteriovenous malformations, aneurysms, mycotic aneurysms, brain tumors, and other pathologies. An MRI will be of limited use in the first one to three months following an intracranial hemorrhage due to the distortion of the local anatomy and obscuration of pathologies by the hemorrhage.

Some teams will nonetheless order such a study to see if they can discern a tumor in the mass. The late MRIs both with and without IV contrast, are generally ordered to rule out the following, associated tumor, cavernous hemangiomas and other lesions. A non emergent carotid and vertebral artery evaluation, for example, a Doppler study and an echocardiogram are often ordered in patients who are discovered to have an intracranial hemorrhage.

These studies look for other ideologies for the hemorrhage when a clear source has not been already identified. Sometimes the venous study through MR venography or CT venography should be considered if the etiology is not clear, particularly if the hemorrhage is intra parenchyma and peripheral in the brain. This may demonstrate a venous sinus occlusion. If a vascular lesion is detected, you may move on to full for vessels cerebral angiography to better characterize and possibly treat it. Treatment of hemorrhagic strokes more often than not, is supportive.

Efforts are made to control intracranial pressure, reduce brain swelling, and keep the rest of the patient's body healthy as the hemorrhage resolves. Once it's clear the patient will be stable attention is rapidly turn to their rehabilitation. Only a select few patients with hemorrhagic strokes go on to surgical intervention. This is not out of cruelty, but out of the fact that surgery has only been shown to be beneficial in a narrow window of associated circumstances.

Surgical decision making is predicated on factors such as hemorrhage location, hemorrhage size, the patient's neurological status, evidence of hemorrhage and or neurological progression, evidence of increased intracranial pressure and herniation, associated hydrocephalus and the patient's age and premorbid condition.