Stroke A] Hemorrhagic stroke

Notes
  • The main causes of this type of stroke (which has high mortality rate) are hypertension, vascular disorders like aneurysms, trauma, post-hemorrhage vasospasms and overdose of anticoagulants.
  • There are two types of hemorrhagic stroke: sub-arachnoid and intracerebral
  • Risk factors for hemorrhagic shock include: hypertension, diabetes, hypercholesterolemia, cardiovascular diseases, smoking, family history, personal history of stroke, old age (above 55yrs), race (higher risks with African-Americans), gender (men have higher risks), pregnancy, child birth, hormonal contraceptives, binge drinking, inefficient physical inactivity and illicit drugs e.g. cocaine and amphetamines.
Symptoms
  • If sub-arachnoid hemorrhage the patient displays symptoms that are similar to those of meningitis such as sudden and severe headache, stiff neck and Kernig’s sign.
  • Hemiparesis

*When left or dominant hemisphere is affected:

 _Right hemiparesis with the right         hemiparesis  loss

 _Preference of left gaze

*When right or nondominant hemisphere is affected:

 _Left hemiparesis with the left            hemiparesis  loss

 _Preference of right gaze

  • Obtundation (altered level of consciousness).
  • Dysarthria (difficulty in talking)
  • Dysphagia
  • Aphasia (difficulty in language)
  • Memory loss
  • Numbness
  • Pain
  • Emotional changes
  • Seizures
  • Vomiting
  • Secondary hydrocephalus
  • Confusion
  • Obtundation (loss of some level of consciousness)
Diagnosis
  • CT Scan (as an emergency)
  • Magnetic Resonance Imaging (MRI)
  • Carotid duplex scanning
  • Lumber puncture in case CT scan is negative (to exclude meningitis or sub arachnoid hemorrhage.
  • Full blood count (to exclude other pos sible causes of stroke such as polycythe mia and leukemia etc.)
  • Other supportive tests include: pregnancy test as some treatment re gimes can affect the fetus negatively),       coagulation tests (in readiness for phar    macotherapy), basic chemistry panels      (such as blood sugar, electrolytes and      urea to rule out symptoms that similar      to stroke); cardiac biomarkers. 
Management
  • Immediate action (within 60 minutes of patient’s arrival):

*Assess airways, breathing and circulation.

*Undertaking initial tests including critical imaging and laboratory tests.

*Identification of reperfusion therapy

  • Pharmacotherapy:

*Fibrinolytics and antiplatelets (useful if administered at least 3hrs after  the symptoms)

**Reteplase at  the following dose: 10U bolus dose followed by a second 10U bolus dose 30 minutes later [double bolus]. Each bolus is administered as a slow intravenous injection within 2 minutes. Heparin and acetylsalicylic acid should be administered before and following its administration to reduce the risk of rethrombosis.

  • Mechanical thrombectomy
  • Management of co-morbid conditions
  • Prophylactic measures include:

*Statins

*Antiplatelets such as aspirin or clopidogrel

*Regular  controlled exercises

*Cessation of smoking, controlled alcoholic intake and other lifestyle interventions.

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