Download Raising Awareness of Hemorrhagic Stroke

Raising Awareness of
Hemorrhagic Stroke
By Kelly A. Taft, RN, BSN
Nursing made Incredibly Easy!
July/August 2009
2.1 ANCC contact hours
Online: 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

Cardiac enzymes and
troponin

Blood urea nitrogen

Creatinine

Serum blood glucose
•

ECG


Complete blood cell
count, including
platelets


Electrolytes
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