1. Presented By: Raymond Chow, Yen Nguyen, Maryam Shirmohamadali

2.  Recognize the epidemiology, pathophysiology, risk
factors, and clinical presentation of hemorrhagic stroke
 Describe the pharmacological and non-pharmacological
options for treatment of hemorrhagic stroke
 Evaluate benefits and risks of different treatment
options
 Understand the importance of risk factor mitigation and
management after hemorrhagic stroke
 Design a pharmacological plan for patients presenting
with acute hemorrhagic stroke

3. CC: “This headache is killing me!”
HPI: GQ is a 60-yo male who presents to the ED with
rapidly progressing numbness of his right arm and a
headache that started early in the morning and has been
getting progressively worse since. He has grown more
incoherent in speech at home with his wife, prompting
her to bring him to the hospital.
He smokes 5 packs a week, and drinks 3-4 cans of beer
every night. History of hypertension, atrial fibrillation,
and states that he has not been taking his BP
medications for the last few months.

4. Allergies: NKDA
Current Meds:
1. Ibuprofen 200mg 1-2 tab q6hr PRN headache
2. Atenolol 25 mg daily
3. Metformin 1000mg BID
4. Warfarin 6 mg daily
PMH:
1. DM II x 25 years
2. HTN x 20 years
3. Hyperlipidemia x 10 years
SH: Smokes 5 ppw x 15 years; drinks 3-4 beers per day

5. ROS:
 Gen: patient is an obese male who appears uncomfortable
and in distress. Pt is experiencing right facial drooping and
right-sided paralysis
 VS: BP 220/155, RR 20, T 38.6, Wt: 120 kg, Ht 180 cm
 BG 164 INR 9.4
 Skin: cold, dry
 HEENT: Right pupil dilated and right eye deviated down and
out
 Heart: RRR, normal S1 and S2
 ABD: nondistended, no guarding
 Neuro: A&O x 1 (oriented to person only)

6.  Stroke is the leading cause of adult disabilities
 2nd leading cause of death worldwide
 3rd leading cause of death in the U.S.
 800,000 strokes per year resulting in 150,000 deaths
 Deaths are projected to increase exponentially in the next
30 years owing to the aging population
 The annual cost of stroke in the U.S. is estimated at
$69 billion
 Stroke can be divided into hemorrhagic and ischemic
origins
 13% hemorrhagic
 87% ischemic

7.  Usually occurs spontaneously
 Caused by vascular rupture with
bleeding into brain
 Mass effect can further cause
bleeding and hematoma expansion
from neighboring vessels
 Hematoma growth over several
hours following presentation of
symptoms is common (30-40%)
 Hemorrhages commonly occurs
at the basal ganglia, thalamus,
pons, or cerebellum

8.  Epidural hematoma: results from damaged artery 
risk for bursting (e.g. meningeal artery)
 Commonly due to head trauma associated with skull
fracture
 Mass effect may occur after several hours
 Subdural hematoma: develops from damaged veins
 leakage of blood to subdural space (e.g. cortical
veins bridging)
 Commonly due to head trauma
 Mass effect may occur after several days
 Common in elderly population

9. http://brainandspine.titololawoffice.com/2011/09/articles/brain-injury/subdural-hematoma-and-epidural-hematoma/

10.  Subarachnoid hemorrhage:
 May result from head injury, rupture of arterial
aneurysm, or spread of blood from different
location to subarachnoid space
 Most common: berry aneurysm
▪ ↑ICP  disrupts blood flow in brain  generalized
concussion

11. Berry Aneurysm
http://www.strokesurvivors.ca/new/AneurysmFAQ.php

12.  Intracranial hemorrhage (ICH):
 Hematomas  focal neurologic deficits due to
pressure pushing against nearby brain structures
 Blood leakage  cause damages to surrounding
brain tissues
 Patients with high blood pressure  most
common cause for non-traumatic ICH

13. Traumatic Non-traumatic
Head injury Uncontrolled hypertension
Anticoagulant therapy
Platelet and coagulation disorders
Vascular malformations
Brain tumors
Cerebral amyloid angiopathy
Drug-induced: cocaine, amphetamines

14.  Chronic hypertension  structural wall changes of small arteries and
arterioles in the brain
 Fibrinoid necrosis
 Charcot-Bouchard aneurysms
 Idiopathic hypertension (acute)  usually younger patients with history
of drug abuse
 Amphetamine, cocaine
 May occur minutes to hours after drug use
 Vascular malformations
 Arteriovenous malformations (AVM): failure of formation of capillary beds
 Saccular (berry): results from developmental weakness of arteriole walls
 Hemorrhages can cause compression to nearby brain tissues
 May result in brain tissue inflammation and edema

15. http://www.uwmedicine.org/patient-care/our-services/medical-services/stroke-center/pages/articleview.aspx?subId=79

16. NON-MODIFIABLE MODIFIABLE
 Age  HTN
 Sex  Cerebral amyloid angiopathy
 Race  Cholesterol
 Asians > Afr. Amer. > White
 Anti-coagulation
 Anti-platelets
 Genetics:
 High EtOH intake
 Cerebral amyloid angiopathy,
 Smoking
coagulation disorders
 DM
 Microbleeds
 Dialysis
 Drug-Induced (e.g. cocaine,
amphetamines)

17. Which of the following risk factors does patient GQ
present with?
a. Age
b. Anticoagulant use
c. Smoking
d. Elevated BP
e. All of the above

18. Subjective
CC: “This headache is killing me!”
HPI: GQ is a 60-yo male who presents to the ED with
rapidly progressing numbness of his right arm and a
headache that started early in the morning and has been
getting progressively worse since. He has grown more
incoherent speech at home with his wife, prompting her
to bring him to the hospital.
He smokes 5 packs a week, and drinks 3-4 cans of beer
every night. Yes history of uncontrolled
hypertension, atrial fibrillation, and states that he has
not been taking BP his medications for the last few
months.

19. Objective
Allergies: NKDA
Current Meds:
1. Ibuprofen 200mg 1-2 tab q6hr PRN headache
2. Atenolol 25 mg daily
3. Metformin 1000mg BID
4. Warfarin 6 mg daily
PMH:
1. DM II x 25 years
2. HTN x 20 years
3. Hyperlipidemia x 10 years
SH: Smokes 5 ppw x 15 years; drinks 3-4 beers per day

20. Test Results
Head CT • Differentiates hemorrhagic from ischemic stroke
ECG • Signs of myocardial ischemia, large inverted T waves
Labs • Chem panel – r/o conditions that have similar
presentation
• CBC – thrombocytopenia
• PT/PTT – w/o coagulopathy as cause
MRI • r/o aneurysm or arteriovenous malformation as a cause
CT of bleeding
• Recommended in all patients <45 years of age and in all
angiography
patients with intracerebral hemorrhage in lobar brain
Invasive regions
angiography

21.  Head CT
http://www.uwmedicine.org/patient-care/our-services/medical-services/stroke-center/pages/articleview.aspx?subId=79

22. Eye Opening (E) Verbal Response (V) Motor Response (M)
4 = spontaneous 5 = normal conversation 6 = normal
3 = to voice 4 = disoriented conversation 5 = localized to pain
2 = to pain 3 = words, but not coherent 4 = withdraws to pain
1 = none 2 = no words, only sounds 3 = decorticate postureα
1 = none 2 = decerebrateβ
1 = none
Assessment:
• Severe: GCS 3-8 (cannot score lower than a 3)
• Moderate: GCS 9-12
• Mild: GCS 13-15
αabnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and
fingers bend and held on the chest
βabnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards)

23.  Mainstay of ICH therapy is to treat the
underlying cause when possible
 General treatment approach is always patient
specific depending on clinical condition

24.  Stabilization of Vital Signs
 Neurological exam
 Supportive care
 Management of seizures
 Blood pressure control
 Fever control
 Anticoagulation correction
 Blood sugar control
 Surgical/Invasive Interventions

25. Objective
 VS: BP 201/155, RR 20, T 38.6, Wt: 120 kg, Ht 180 cm
 BG 164 INR 9.4
 Skin: cold, dry
 HEENT: Right pupil dilated and right eye deviated down and
out
 Heart: RRR, normal S1 and S2
 ABD: nondistended, no guarding,
 Neuro: A&O x 1 (oriented to person only)
 EEG normal
 Other: CT reveals areas of hyperintensity

26.  Patients with elevated INR due to anticoagulant use
 Hold warfarin, give clotting factors , and vitamin K (IVPB)
▪ FFP or PCCs
 Patients with a severe coagulation factor deficiency
or severe thrombocytopenia
 Factor replacement therapy or platelets
▪ Recombinant Factor VIIa (rFVIIa)
 New recommendation; 2010 Guidelines

27.  Replenishment of Clotting Factors:
FFP PCCs
Historically recommended Rapid reconstitution and
administration
• Increased risk of allergic & • Processed clotting factors
infectious rxns • Inactivated infectious agents
Large Volumes Small volumes
- Fluid overload
 Note: No difference in clinical outcome with FFP vs. PCC’s but PCCs lead
to less complications

28.  Use of platelet transfusions in ICH patients with
a history of antiplatelet use is unclear
 May be indicated for patients with severe
thrombocytopenia
 Intermittent pneumatic compression
recommended
 May consider low dose SQ LMWH or UFH for
prevention of DVT
 After 1 to 4 days from onset with lack of mobility

29.  Use of prophylatic anticonvulsant therapy in
ICH is controversial
 Patients with a change in mental status and
whose EEG shows electrographic seizures
should receive tx
 Benzodiazepenes
 Phenytoin/fosphenytoin

30.  Goal SBP to < 180 mm Hg within 1 hour is and
maintain for next 24 hours
 INTERACT study suggests more aggressive
therapy with goal SBP < 140 mm Hg leads to
better outcomes

31.  Antihypertensive agents for ICH have not been
compared in controlled trials
 Suggested agents:
 Labetolol
 Enalapril
 For reftractory hypertension:
 Nicardipine
 Hydralazine
 Nitroprusside
▪ Can lead to elevated ICP

32. Condition Treatment Approach
SBP > 200 mmHg or MAP is 150 mmHg Aggressive BP with continuous IV infusion,
with frequent BP monitoring Q5 min
SBP is 180 mmHg or MAP is 130 mmHg Monitor ICP and BP using intermittent or
continuous IV meds while maintaining cerebral
and
perfusion pressure 60 mmHg
there is the possibility of ICP
SBP is 180 mmHg or MAP is 130 mmHg Modest  BP (eg, MAP of 110 mm Hg or target
BP of 160/90 mm Hg) using intermittent or
and
continuous IV meds to control BP and clinically
there is no evidence of ICP reexamine the patient Q15 min

33.  Elevate head of bed to 30 degrees
 Analgesia and sedation as needed
 Aggressive therapies:
 Osmotic therapy
▪ Mannitol
▪ RCT failed to demonstrated difference in disability or death at 3
months
▪ Hypertonic Saline
▪ Barbituate anesthesia
 Hyperventilation and glucocorticoids not
recommended

34.  CSF drainage may be appropriate in setting
of obstructive hydrocephalus
 High rates of complication : bacterial meningitis
 Endoscopic hematoma Evacuation
 May improve long-term prognosis

35.  High blood glucose on admission predicts an
increased risk of mortality and poor outcome
in patients with and without diabetes and ICH
 Use of insulin is controversial. Hypoglycemia
should be avoided.

36. Which of the following regarding PCCs and FFP
is correct?
a. FFP has historically been used because it results in better
overall clinical outcome for patients
b. Use of FFP leads to more fluid overload compared to
PPC’s
c. More allergic reactions occur with PCCs than FFP
d. FFP use is generally safer than treatment with PCCs

37.  Coil embolization
 Occlusion of aneurysm
 Gaining preference
 Neurosurgical clipping
 More invasive

38. Which of the following is true?
a. FFP has historically been used because they result in
better overall clinical outcome for patients
b. Use of FFP can lead to fluid overload but PCCs don’t run
this risk
c. More allergic reactions occur with PCCs than FFP
d. FFP use is generally safer than treatment with PCCs

39.  Fever has been related to worsening
outcomes
 Hypothermia protocol
▪ For patients with suspected neurologic deficits
▪ Rigorous monitoring required
▪ Core body temp cooled to ~33 degrees
▪ Intubation and mechanical ventilation usually required
 APAP

40.  Delirium
 May be fairly common following ICH
 Therapy: supportive care, sedatives and neuromuscular
blockade, careful hemodynamic management
 Deep venous thrombosis
 Motor weakness, venous stasis
 Therapy: anticoagulation, inferior vena cava filter
 Infection
 Nosocomial pneumonia, urinary tract infection, cellulitis
from pressure sores
 Therapy: appropriate broad-spectrum coverage, then
narrowing for cultured organisms

41.  Aspiration pneumonia
 Stroke-related dysphagia
 Therapy: dysphagia/swallow evaluation before moving to PO
status
 Hydrocephalus
 Elevation of CSF pressure of the brain
 Cognitive impairment, urinary/fecal incontinence
 Therapy: external ventricular drain placement,
ventriculoperitoneal shunt
 Seizures
 May complicate treatment for ICH; higher risk in cortical
bleeding
 Therapy: benzodiazapines, phenytoin, fosphenytoin

42.  Lifestyle modifications:
 smoking cessation, refrain from alcohol,
diet/exercise, weight control
 Control blood pressure
 Control LDL
 Clot prevention: Warfarin, Aggrenox, Plavix

43. Which medications can be used for the prevention
of a stroke?
i. Warfarin
ii. Alteplase
iii. Phytonadione
A. I only
B. III only
C. I and II
D. II and III
E. I, II, and III

44.  Lobar location of initial ICH
 Uncontrolled hypertension
 Older age
 Ongoing anticoagulation
 Apolipoprotein E epsilon 2 or epsilon 4 alleles
 Greater number of microbleeds on MRI

45. Which of the following factors can directly increase the
likelihood for patients to have another intracranial
bleeding event?
i. Uncontrolled HTN
ii. Use of warfarin
iii. Lifestyle (e.g. smoking, excessive exercising)
A. I only
B. III only
C. I and II
D. II and III
E. I, II, and III

46. Assessment/Plan
1. SBP Above Recommended Value Of < 140 mm
Hg Per AHA Stroke 2010 Guideline
 Esmolol 30mg IVP, Then 3mg/min Continuous IV
2. Supratherapeutic INR, Likely To Have
Contributed To Initial Bleeding Event
 Hold Warfarin
 Give Vitamin K 10mg IV Infusion
 Give 3 Units FFP or PCCs
 Goal INR < 1.0 Due To Life-threatening Bleed

47. Assessment/Plan
3. ICP monitoring to goal CPP ≥ 60 mmHg
 Appropriate analgesia and sedation
 Head of bed elevation
 IV Mannitol
4. Seizure prophylaxis not indicated as no EEG
abnormalities
 Continue EEG monitoring

48.  Monitoring by appropriate specialists for
rehabilitation
 Physical therapist, occupational therapist, speech
and language pathologist
 Strict management of HTN
 Antiplatelet/anticoagulation therapy

49.  Greenberg D.A., Aminoff M.J., Simon R.P. (2012). Chapter 3. Coma. In D.A.
Greenberg, M.J. Aminoff, R.P. Simon (Eds), Clinical Neurology, 8e. Retrieved
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www.accessmedicine.com.library.touro.edu/content.aspx?aID=56670556.
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management of spontaneous intracerebral hemorrhage: a guideline for
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