GEMORRAGIC STROKE.

STROKE PREVENTION

HEMORRAGIC STROKE

Rupture of abnormal artery or Outbreak of blood in microaneurism, bleeding into the subarachnoid space the substance of the brainand formation of hematoma

intracerebral or intraventricular hemorrhage (2/3)

subarachnoid hemorrhage (1/3)

Intracerebral hemorrhage

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

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

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

intraceribral hemorrhage

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

Localization of hematoma

Intraceribral hemorrhage with rupture into the ventriculal system

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)

Diagnosis of intracerebral hemorrhage

CT-scan MR-angiography or contrast cerebral

аngiography to identify a possible aneurysm or arteriovenous malformation

Later MRI

Right parietal hemorrhage Right parietal hemorrhage ((CTCT))

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

Intraventriculal hemorrhageIntraventriculal hemorrhage

Intracerebral hemorrhage in different periodsIntracerebral hemorrhage in different periods

1 1 dayday 7 7 daysdays 16 16 daysdays

Arteriovenous malformation

CТMR-аngiography

MRI

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

SUBARACHNOID

HEMORRHAGE

ETIOLOGY OFSUBARACHNOID HEMORRHAGE

• Rupture of aneurysm (in 60-70% сases)

- saccular aneurysm - arteriovenous malformation Rare: complication in treatment

with anticoagulants, thrombolytics

Hematological disorders Unknown etiology

ETIOLOGY OFSUBARACHNOID 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

Localization of saccular aneurysmLocalization of saccular aneurysm

Accumulation of blood in subarachnoid space results in

severe headache

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

Diagnosis of subarachnoid hemorrhage

CT scanLumbar punctureMR-angiography or contrast cerebral

аngiography

CT AND МRI IN SUBARACHNOID HEMORRAGE

Lumbar puncture

The presence of blood in CSF

Contrast аngiographySaccular аneurysm in blood vessels

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

Vasospasm and cerebral ischemia in subarachnoid hemorrhage

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

Indications for surgical treatment in intracerebral hemorrhage

• Large (>40 ml) and superficial hematoma with brain compression signs

• Acute hydrocephaly• Large hematoma in

cerebellum

TREATMENT OF SUBARACHNOID HEMORRHAGE

Strict bed regimenSurgical treatment (in presence of aneurism)Ca-antagonists (nimodopin) - prevention for

secondary vasospasmMonitoring of BP, ECG, blood glucose,

electrolytesAnalgetics (in severe headache)

Coil Embolization

Aneurysm clipping

COMPLICATIONS OF SUBARACHNOID HEMORRHAGE

Cerebral vasospasm (possible ischemic stroke)

Recurrent subarachnoid hemorrhage

Brain edema and hydrocephaly

SECONDARY STROKE

PREVENTION

RISK FACTORS FOR ISCEMIC STROKE

Arterial hypertension (>140mmHg systolic, >90mmHg diastolic)

Heart diseases (atrial fibrillation)

Stenosis of corotid artery (>70%)

HyperlipidemiaDiabetes 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

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

Carotid endarterectomy

Carotid stenting