HEMORRHAGIC STROKE

HEMORRHAGIC STROKE

1. Main Causes

   • Risk Factors (Davis & Lockhart, 2016).
     • Modifiable
       • Atrial Fibrillation
       • Smoking
       • Hypertension
       • History of TIA, previous stroke, or myocardial infarction
       • Diabetes Mellitus
       • Sedentary Lifestyle
       • Hormone Replacement Therapy
       • Socioeconomic Status
     • Non-modifiable
       • Female Sex (ages 55-75) at higher risk
       • Age >45
       • Hereditary
       • Black, Hispanic or Asian ethnicity
     • Probable
       • Sleep Apnea
       • Substance abuse or alcoholism
       • Arteriovenous Malformation
         • An abnormal or weak blood vessl that connects the artery and vein
           • Can stretch or leak causing hemorrhage
           • Present from birth
       • Stress
       • Burst aneurysm

2. Manifestations (Lewis, 2014)

   • Signs
     • General
       • Emotional lability, lethargy, apathy or combativeness, fever
     • Respiratory
       • Loss of cough reflex
       • laboured or irregular respirations
       • tachypnea
       • wheezing (aspiration)
       • airway occlusion (tongue)
       • Apnea
       • Coughing while eating
     • Cardiovascular
       • tachycardia,
       • Hypertension
       • Carotid bruit
     • Gastrointestinal
       • Loss of gag refelx
       • Bowel incontinence
       • Absent bowel sounds
       • constipation
     • Urinary
       • Frequency
       • Urgency
       • Incontinence
     • Neurological
       • Flaccidity followed by spasticity
       • Visual deficits
       • Akinesia, dysarthria, agnosias, apraxia.
       • unequal pupils and hand grasps
       • Contralateral motor and sensory deficits,
         • Weakness, paresis, paralysis, anaesthesia
       • Altered level of consciousness
       • Aphasia
         • Expressive, receptive and global
       • perceptual or spatial disturbances
   • Symptoms
     • Anorexia, nausea, vomiting
     • Change in bowel and bladder patterns
     • Loss of memory
     • Numbness, tingling of one side of the body
     • Dysphagia, altered sensation of taste and smell
     • Alteration in speech, language, problem-solving ability
     • Loss of movement and sensation
     • Generalized weakness
     • Figure 6

3. Diagnostic Testing

   • Computed tomography scan
     • A computed x-ray image that produces a 3D (cross-sectional) visual of organs, tissues, bones and blood vessels in the body. It requires a contrast medium to be administered before the procedure either orally, intravenously or as an enema (American Society of Neuroradiology, 2017).
       • Used to detect abnormalities or disease by viewing the brain, chest, abdomen or pelvis
   • Computed tomography Angiography
     • 3D images of blood vessels in the brain are viewed with an IV injection of a contrast dye. For hemorrhagic stroke, the CT angiography will show aneurysms, arteriovenous malformation and other signs of bleeding (Macellari, F. et al., 2014)
       • Useful in determining secondary causes of hemorrhage
   • Lumbar Puncture for Subarachnoid Hemorrhage
     • A needle is inserted into the back to obtain a sample of cerebrospinal fluid to examine if it contains blood (American Society of Neuroradiology, 2017).
     • Figure 2
   • MRI
     • Produces 3D diffusion weighted images that measures the speed at which water molecules diffuse in different parts of the brain. If a stroke is present diffusion will be slow in the affected areas (American Society of Neuroradiology, 2017).
       • Figure 1

4. Treatment and Management

   • Surgical Interventions (Davis & Lockhart, 2016)
     • Superficial Temporal Artery to Middle Cerebral Artery Bypass Graft
       • A bypass graft improves blood flow to the heart, for a hemorrhagic stroke a superficial temporal atrery is grafted to bypass the cerebral vessel containing the thrombus or unruptured aneurysm
     • Guglielmi Detachable Coils
       • Platinum coils are used to seal a ruptured or unruptured aneurysm
     • Aneurysm Clipping
       • To stop or prevent a ruptured or unruptured anuerysm from bleeding, clips are used to seal the aneurysm
         • Figure 5
     • Decompressive Craniotomy
       • A flap is created in the skull, to visually see the aneurysm and place clips to seal the bleeding
         • A less commonly used approach due to the aggressive procedure to manage a hemorrhagic stroke
   • Medication (Rymer, 2011).
     • Pain Management
       • Muskuloskeletal shoulder pain
         • Corticosteroid injections can be used to treat shoulder pain
       • Neuropathic central post-stroke pain
         • Antidepressants and anticonvulsants are found to be effective in improving the pain scores in patients with CPS
           • Example: Amitriptyline
     • The main drug therapy for patients with hemorrhagic stroke is the management of hypertension. Oral and IV agents may be used to maintain BP within a normal to high-normal range (systolic BP <160!mm Hg)
       • Calcium Channel Blockers
         • Used for primary or secondary stroke prevention
           • Blocks the entry of calcium to reduce electrical conduction within the heart, decreasing the force of contraction and dilating arteries
             • Assess BP and apical pulses before administration. If pulse <60 beats/min or systolic BP <90mm Hg, hold medication and contact physician
               • Example: Nimodipine
                 • Firgure 7
       • Beta Blockers
         • Works by blocking the effects of the hormone epinephrine, causing the heart to beat slowly with less force
           • Example: Labetalol & Esmolol
       • ACE Inhibitors
         • Acts on the RAS by blocking the conversion of angiotensin I to angiotensin II by inhibiting the ACE
           • Obtain blood pressure immediately before each dose
             • Example: Enalapril
     • Osmotic Agents
       • Used to decrease intracranial pressure in the subarachnoid space.
         • Monitor urinary output, electrolytes, ICP, renal fnction, LFT and wieght daily
           • Example: Mannitol and hypertonic saline
     • Anticonvulsant Therapy
       • Seizure prophylaxis in the acute period after intracerebral and subarachnoid hemorrhages is recommended
         • In these patients, seizure activity may result in further neuronal injury and contribute to a coma
         • Example: Gabapentin
   • Goals of Treatment (Lewis et al., 2014)
     • Pain Management
       • This is essential in promoting optimal healing and preventing complications
     • Control ICP, BP and BS
       • Elevated blood pressure after stroke is compensating to maintain cerebral perfusion (Lewis et al., 2014).
       • Increased intracranial pressure occurs with hemorrhagic stroke, peaking at 72 hours, can lead to brain herniation
         • Management for increased intracranial pressure includes: improving venous drainage by elevating the head of the bed, maintaining head and neck alignment and avoiding hip flexion (Lewis et al., 2014)
     • Prevention of secondary injury
       • Hyperthermia can cause further damage because it increases brain metabolism. Elevation by 1 degree celsius can increase the brain's metabolism by 10% (Lewis et al., 2014)
     • Restore optimal function
       • Physical, occupational, and speech therapy
     • Stop the bleeding
     • Treat underlying cardiac problem
     • Maintain adequate nutrition
       • Dysphagia may put patients at risk of malnutrition which can exacerbate brain damage and contribute to adverse outcome.
         • Dietary modifications or specific therapeutic strategies should be put in place to ensure adequate nutritional intake
   • Nursing Interventions (Lewis et al., 2014)
     • Frequent assessment of Circulation, Airway, Breathing are priority
     • Nurse should monitor vital signs every 15 minutes
       • Critical to keep the patient out of hypertensive state because it can expand the bleed and worsen the injury to the brain
       • Monitor glucose
     • DVT prevention
       • Patient is at risk of DVT because of immobility, loss of venous tone, decreased muscle pumping activity in leg
         • Patients should be encouraged to walk, do leg exercises, and use compression stockings
     • Neurological System
       • Monitor the neurological status hourly for changes. Monitor the respiratory status, PaO2, PaCO2, pH and bicarbonate levels to assess the neurological status. Administer and titrate vasoactive drugs to maintain homeostasis. (Lewis et al., 2014)
       • Must be monitored for changes in extension of stroke, increased ICP, vasosapsm, recovery from stroke symptoms
         • Tools used to monitor the neurological system are Glasgow Coma Scale, National Institution of Health Stroke Scale and the Canadian Neurological Scale
           • Glasgow Coma Scale measures LOC, mental status, pupillary responses, extremity movement and strength
           • The Canadian Neurological Scale measures LOC, orientation, speech and motor responses of the face, arms and legs
     • Cardiovascular System
       • Monitor the intake and ouput, central venous pressure and pulmonary artery pressure because they indicate fluid balance and cardiac function
         • Monitor cardiac rhythms, calculate intake and output, regulate IV infusions, adjust fluid intake to patient's needs, monitor lung sounds for pulomnary congestion, monitor heart sounds for S3 murmurs and S4 heart sounds
     • Musculoskeletal System
       • The goal is to maintain optimal function, prevent joint contractures and muscular atrophy
         • Passive range of motion begins first day of hospitalization and patient must begin actively exercising as soon as possible
           • To optimize musculoskeletal function perform trochanter roll at hip to prevent external rotation, hand cones to prevent contractures, arm supports with slings and lap boards to prevent shoulder displacement
         • To prevent dependent edema, position the joint higher than joint proximal to it
     • Integumentary System
       • Skin is suscpetible to breakdown due to loss of sensation, decreased circulation and immobility
         • To prevent skin breakdown provide pressure relief by position changes, good skin hygiene, emollients applied to dry skin, and early mobility
           • Ideal position change is side-back-side, 2 hours each position
             • Figure 6
     • Gastrointestinal System
       • Constipation is the most common problem
         • Prophylaxis protocol includes stool softners and/or fibre
     • Nutrition
       • A speech-language pathologist will perform a swallow evaluation before the patient begins oral intake
         • The gag reflex is stimulated with a tongue blade before initiating the feed
         • The nurse should screen the patient's swallow ability by elevating the head of the bed, with the an upright position and administer 3 tsp of water to the patient, then 50 mL by cup
         • Food list will be provided by speech pathologist that are easy to swallow and stimulate a swallow reflex. For example crushed ice.

5. Health Education (Intracerebral Hemorrhage, 2019).

   • Patients and caregivers will be educated on the warning signs of a stroke by utilizing the acronym F.A.S.T.
     • Call 911 if you or anyone else expperiences any of the following F = Face: One side of the face droops. A = Arms: One arm starts to drop when both arms are raised. S = Speech: Speech is slurred or sounds different than usual. T = Time: A person who is having a stroke needs to be seen immediately
       • Other warning signs include (Lewis et al., 2014)
         • Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
         • Sudden confusion, trouble speaking or understanding
         • Sudden trouble seeing in one or both eyes
         • Sudden trouble walking, dizziness, loss of balance or coordination
         • Sudden, severe headache with no known cause
   • Healthy Lifestyle
     • Limit Alcohol intake
       • Men should have no more than 2 alcoholic drinks a day. Women should limit themselves to 1 alcoholic drink per day.
     • Maintain a healthy weight
     • Manage stress
       • Deep breathing
       • Meditate
       • Yoga
       • Get enough sleep
     • Monitor blood pressure
       • Uncontrolled high blood pressure can lead to stroke by damaging and weakening your brain's blood vessels, causing them to narrow, rupture or leak
     • Control blood sugar
       • High blood sugar levels can damage blood vessels and nerves, making a stroke more likely
     • Diet and exercise
       • Reduce sodium, fat, cholesterol, and processed foods
       • Ask your provider how to get started and how much activity you should try to get on a daily or weekly basis. You can benefit from simple activities such as walking.
         • Figure 3
       • Eat more fruits and vegetables, lean proteins, such as fish, poultry, and beans and peas (legumes)
     • Take medication as prescribed. Do not skip a dose
       • Blood pressure medication adherence is important as hypertension is the primary cause of stroke
         • Side effects of bp medication may include a cough, erectile dysfunction or leg swelling. If these occur contact your doctor and he will switch you to another class of bp drug (Hrvard University, 2017)
     • Smoking cessation
       • Smoking contributes to the buildup of plaque in your arteries, increases the risk of blood clots, reduces the oxygen in your blood, and makes your heart work harder.
         • Significantly increases the risk of a recurrent stroke
       • Figure 4

6. Definition & Classifications (Harvard University, 2019)

   • Hemorrhagic stroke is defined as the extravasation of blood into the brain parenchyma
     • Intracerbral Hemorrhage
       • Bleeding occurs from ruptured blood vessel within the brain. 50% occurs in the putamen and internal capsule, central white matter, thalamus, cerebellar hemispheres,, and pons. (Lewis et al., 2014)
         • Hemorrhage commonly occurs during periods of activity
           • ICH should be suspected in any patient who presents with a sudden onset of focal neurological deficit in the setting of headaches and hypertension.
         • Manifestations related to putaminal and internal capsule bleeding are: weakness of face, arm and leg on one side, slurred speech, deviation of eyes
         • Hemorrhage in pons location affects basic life functions such as respirations and is characterized by complete paralysis, coma, abnormal body posturing, fixed (small) pupils, hyperthermia and death
     • Subarachnoid Hemorrhage
       • Occurs when there is intracranial bleeding into the cerebrospinal fluid (CSF)– filled space between the arachnoid and the pia mater membranes on the surface of the brain (Lewis et al., 2014)
         • Results due to leaking of saccular aneurysm or leakage from arteriovenous malformation
           • SAH presents as the worst headache of ones life.
   • "A stroke is like a small part of the brain is drowning, and if you don't re-establish blood flow within a very short period of time, part of the brain is irreversibly damaged" (Metamania, 2015)

7. Nursing Assessment (Lewis et al., 2014)

   • Subjective
     • Description of current illness with initial symptoms (onset, duration, nature, changes)
     • History of similar symptoms experienced
     • Current Medications
     • History of risk factors and other illnesses
     • Family history of stroke and cardiovascular diseases
   • Objective
     • Level of consciousness
     • Cognition
     • Motor abilities
     • Cranial Nerve Function
     • Sensation
     • Proprioception
     • Cerebellar function
     • Deep tendon reflexes

8. Discharge and Home Care( Lewis et al., 2014)

   • Critical factor in discharge is the patient's ability to perform activities of daily living
     • Interdisciplinary team will make referrals for needed equipment and services
       • The nurse is responsible for education, demonstration, return demonstration, practice, evaluation and self-care skills
         • Discharge planning and education should include medications, nutrition, mobility, exercises, hygiene, and toielting
           • Follow up care for continuing nursing care, physiotherapy, occupational therapy and speech therapy
       • Stroke rehabilitation team includes rehabilitation nurse, neuropsychologist, occupational therapit, physiotherapist, physician, recreational therapist, social worker and SLP

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