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.

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• 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

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• 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).

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• 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.

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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

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• (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.

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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.

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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.

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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.

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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.

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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 .

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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.

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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.

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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.

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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.

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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.

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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).

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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).

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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 .

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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) .

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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.

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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

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Nursing ProcessThe Patient With a Hemorrhagic
Stroke

• Assessment
• A complete neurologic assessment is performed
  initially and includes evaluation for the
  following

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• 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

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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)

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Collaborative Problems/Potential Complications

• Based on the assessment data, potential
  complications that may develop include the
  following
• Vasospasm
• Seizures
• Hydrocephalus
• Rebleeding
• Hyponatremia

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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.

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• 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.

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• 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

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• 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

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

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• 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)

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• 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

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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?