Hemorrhagic strokes

When the CAST collaborative group performed a meta-analysis of 1ST, CAST, and MAST-I, the trend seen in CAST and 1ST toward a beneficial effect of aspirin on the rate of death or dependency reached the threshold for statistical significance. Early aspirin therapy (160-300 mg/day) conferred an absolute reduction in the rate of recurrent ischemic stroke by 0.7% (7 per 1000 patients treated) (p < 0.001) and reduced the rate of death or dependency by 1.3% (13 per 1000 patients treated) (2p = 0.007). Aspirin caused about 2 hemorrhagic strokes among every 1000 patients treated, but prevented about 11 other strokes or deaths in hospital. 

Identify the modifiable and non-modifiable risk factors associated with ischemic stroke and hemorrhagic stroke. 

Hemorrhagic stroke is a result of bleeding into the brain and other spaces within the central nervous system and includes subarachnoid hemorrhage, intracerebral hemorrhage, and subdural hematomas. 

All patients should have a brain computed tomography scan or magnetic resonance imaging scan to differentiate an ischemic stroke from a hemorrhagic stroke, as the treatment... 

The pathophysiology of hemorrhagic stroke is not as well studied as that of ischemic stroke however, it is a more complex process than previously thought. Much of the process is related to the presence of blood in the brain tissue and/or surrounding... 

Assessment of risk factors for ischemic stroke as well as for hemorrhagic stroke is an important component of the diagnosis and treatment of patients. A major goal in the long-term treatment of ischemic stroke involves the prevention of a recurrent stroke through the reduction and modification of risk factors. The major focus of primary prevention (prevention of the first stroke) is also reduction and modification of risk factors. Risk factors for ischemic stroke can be divided into modifiable and non-modifiable factors. Every patient should have risk factors assessed and treated, if possible, as management of risk factors can decrease the occurrence and/or recurrence of stroke.4... 

The patient may complain of weakness on one side of the body, inability to speak, loss of vision, vertigo, or falling. Stroke patients may complain of headache however, with hemorrhagic stroke, the headache can be severe. 

Randomized trials have been completed assessing the role of antiplatelet therapy with aspirin for primary stroke prevention. The use of aspirin in patients with no history of stroke or ischemic heart disease reduced the incidence of non-fatal myocardial infarction (MI) but not of stroke. A meta-analysis of eight trials found that the risk of stroke was slightly increased with aspirin use, especially hemorrhagic stroke. Major bleeding risk was also increased with aspirin use.4 Aspirin is beneficial in the primary prevention of MI, but not for primary stroke prevention. 

In the emergency department an IV line is placed, a physical and neurologic exam is completed, and GR is moved to the stroke unit. The CT scan is negative for hemorrhagic stroke. 

Perform a CT scan to rule out a hemorrhagic stroke prior to administering any treatment. 

Hemorrhagic conversion Conversion of an ischemic stroke into a hemorrhagic stroke. 

Hemorrhagic strokes account for 12% of strokes and include subarachnoid hemorrhage, intracerebral hemorrhage, and subdural hematomas. Subarachnoid hemorrhage may result from trauma or rupture of an intracranial aneurysm or arteriovenous malformation. Intracerebral hemorrhage occurs when a ruptured blood vessel within the brain parenchyma causes formation of a hematoma. Subdural hematomas are most often caused by trauma. 

The presence of blood in the brain parenchyma causes damage to surrounding tissue through a mass effect and the neurotoxicity of blood components and their degradation products. Compression of tissue surrounding hematomas may lead to secondary ischemia. Much of the early mortality of hemorrhagic stroke is due to an abrupt increase in intracranial pressure that can lead to herniation and death. 

Patients with hemorrhagic stroke should be assessed to determine whether they are candidates for surgical intervention via an endovascular or craniotomy approach. 

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