Raising Awareness of Hemorrhagic Stroke

By Kelly A. Taft, RN, BSNNursing made Incredibly Easy! July/August 20092.1 ANCC contact hoursOnline: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Stroke Statistics

Third leading cause of death in the U.S.

800,000 Americans experience stroke each year

30% become permanently disabled

20% require institutional care 4 months after the stroke

Definition of Stroke

Acute focal neurologic deficit

Caused by a vascular disorder that injures brain tissue

Two main types: ischemic and hemorrhagic

• Ischemic: caused by interruption of blood flow in a cerebral vessel

• Hemorrhagic: rupture of a cerebral blood vessel

Hemorrhagic Stroke

Spontaneous hemorrhage into the brain

Accounts for the minority of cases

Most frequently fatal stroke

Most common etiology for individuals ages 18 to 45

Hemorrhagic Stroke Causes

Intracranial hemorrhage: bleeding directly into brain matter (accounts for 41% of hemorrhagic stroke)

• Usually occurs in bifurcations of major arteries• As a result of hypertensive hemorrhage (leads to hyperplasia within the vessel wall, which can lead to “breaks”), atherosclerosis, brain tumors, or certain medications

Subarachnoid hemorrhage: bleeding surrounding the brain tissue

• From arteriovenous malformation (AVM), trauma, or aneurysm

20% are of unknown etiology

Picturing Two Types of Hemorrhage

Cerebral Aneurysm

Cerebral aneurysm: dilation of the walls of cerebral arteries that develops as result of weakness in the wall

• Causes: atherosclerosis, congenital defect,

hypertensive vascular disease, and trauma

• Commonly affected arteries: internal carotid, anterior cerebral, anterior and posterior communicating, and middle and posterior cerebral

Picturing Cerebral Aneurysm

AVM

AVM: complex tangle of abnormal arteries and veins that lack a capillary bed and are linked by one or more fistulas

• Blood is shunted from the high pressure arterial system to the low pressure venous system

• Exposing the draining venous channels them to high pressures and predisposing them to rupture

Brain Edema

Two types: vasogenic and cytotoxic

• Vasogenic: influx of fluid and solutes into the brain; develops rapidly after injury

• Cytotoxic: cellular swelling occurs in brain ischemia and trauma

Brain edema leads to increased intracranial pressure (ICP), tissue shifts, and brain displacement

Major Risk Factors for Hemorrhagic Stroke

Obesity

Hypertension

Cigarette smoking

Excessive alcohol intake

Genetic predisposition for aneurysm formation

Male gender

Increased age

African American or Hispanic descent

Symptoms of Hemorrhagic Stroke

Hemiparesis

Confusion

Dizziness or loss of balance

Difficulty speaking or understanding speech

Sudden severe headache

Loss of consciousness

Nuchal rigidity

Visual disturbances

Tinnitus

Immediate Complications of Hemorrhagic Stroke

Cerebral hypoxia

Decreased cerebral blood flow

Extension of the area of injury

Vasospasm: 40% to 50% of the mortality associated with subarachnoid hemorrhage

Vasospasm

Associated with increasing amounts of blood in the subarachnoid cisterns and fissures

Leads to increased vascular resistance

Impedes cerebral blood flow and causes brain ischemia and infarction

Frequently occurring 4 to 14 days after initial hemorrhage

Signs & symptoms: worsening headache, decreased LOC, and new focal neurologic deficits

Diagnostic Tests for Hemorrhagic Stroke

History and physical exam:

• Rapidity of symptoms • Time of onset • Pattern of symptoms • Mental status • Medications patient is

taking

ECG

Complete blood cell count, including platelets

Electrolytes

Cardiac enzymes and troponin

Blood urea nitrogen

Creatinine

Serum blood glucose

Prothrombin time, INR, partial thromboplastin time

Oxygen saturation

Imaging Studies for Diagnosing Hemorrhagic Stroke

Computed tomography scan: used to determine type of stroke, size, location, and presence of cerebrospinal fluid

Cerebral angiography: used to confirm diagnosis of cerebral aneurysm or AVM

Lumbar puncture: used to confirm subarachnoid hemorrhage

Hunt-Hess Classification of Subarachnoid Hemorrhages

1: Asymptomatic or mild headache and nuchal rigidity (stiff neck)

2: Cranial nerve (CN) palsy (oculomotor [CN III] or abducens [CN VI]), moderate to severe headache, and nuchal rigidity

3: Mild focal deficit, lethargy, or confusion 4: Stupor, moderate to severe hemiparesis, and

early decerebrate rigidity 5: Deep coma, decerebrate rigidity, and moribund

appearance

Add one grade for serious systemic disease (such as hypertension or chronic obstructive pulmonary disease) or severe vasospasm on angiography

NIH Stroke Scale

Important tool in the diagnosis of acute hemorrhagic stroke in patients with sudden onset of symptoms

Should be readily available to all healthcare professionals who are in direct contact with patient treatment and identification of stroke

Treatment Goals for Hemorrhagic Stroke

Consists of a combination of medical and surgical interventions

“Window of opportunity” in which viable brain tissue can be saved

Goal of medical treatment is to allow brain to recover from bleeding and prevent or minimize rebleeding

Medical Interventions for Hemorrhagic Stroke

Patient should be monitored closely in the ICU

Bedrest with sedation to prevent agitation and stress

Analgesics for head and neck pain

Minimize external stimuli

Control of blood glucose levels

ICP and BP will be managed

Seizure management (as recommended by the AHA)

Surgical Interventions for Hemorrhagic Stroke

Removal of hemorrhage via craniotomy (recommended for cerebral hemorrhage greater than 3 cm in diameter)

In aneurysms that haven’t ruptured, the surgical goal is to prevent bleeding

Less invasive procedures include aneurysm coiling or obstruction

Clipping an Aneurysm

Complications of Hemorrhagic Stroke

Rebleeding

Psychological symptoms: disorientation, personality changes, amnesia

Intraoperative embolization

Postoperative artery occlusion

Fluid & electrolyte disturbances

Gastrointestinal bleeding

Neurologic Nursing Assessment After Stroke Treatment

Altered LOC

Sluggish pupillary reaction

Motor and sensory dysfunction

Cranial nerve deficits

Speech and vision difficulties

Headache, nuchal rigidity, other neurologic deficits

Vital sign changes, including an increase or drop in ICP, BP, or heart rate

Rehabilitation After Hemorrhagic Stroke

Begins in the acute phase

Goal is to return the patient to the highest level of functioning independently while improving quality of life

Focus on home and community capabilities

Works best when patient, family, and healthcare providers work as a team

Rehabilitation Components

Preventing complications

Treating disabilities

Improving function

Providing adaptive tools

Altering the environment as appropriate

Patient/family teaching

Patient and Family Teaching

Signs and symptoms of stroke

Measures to prevent subsequent strokes

Potential complications

Psychosocial consequences

Safety measures to prevent falls

Medications

Adaptive techniques

Appropriate exercise

Diet modifications

How to measure BP and when to report to healthcare provider

Importance of keeping follow-up appointments