Hemorrhagic Strokes

Question 1

Types of cerebral hemorrhages?

Answer 1

Subarachnoid hemorrhage (SAH)
Intracerebral hemorrhage (ICH)
Epidural hemorrhage (EDH)
Subdural hemorrhage (SDH)

Question 2

Most common cause of subarachnoid (SAH) hemorrhage?

Answer 2

Rupture of a berry or saccular aneurysm

Question 3

What are berry aneurysms?

Answer 3

Developmental defects in the blood vessel wall that tend to enlarge with time

Question 4

What size aneurysms typically rupture and bleed?

Answer 4

Those > 5mm

Question 5

Most common locations of a berry aneurysm?

Answer 5

Anterior Cerebral Artery (30%), Internal Carotid (30%), Middle Cerebral (25%), Posterior Cerebral (2%), Basilar (10%), Vertebral-PICA (2%)

Question 6

Risk factors for SAH?

Answer 6

Tobacco use
EtOH abuse
HTN
Oral contraceptives
Stimulant drugs
Low cholesterol
Genetics - Polycystic kidneys, Marfan's Syndrome

Question 7

Symptoms of SAH?

Answer 7

Sudden, severe headache - “Worst headache of my life”
Rapid loss of consciousness (Some not all pts)
Neck stiffness/pain
Phonophobia
Photophobia
Nausea/vomiting
Focal neurologic signs are minimal or absent

Question 8

Signs of SAH?

Answer 8

Abnormal vital signs - elevated BPs, arrhythmias

Retinal hemorrhages

Question 9

What is the most important dx tool to identify SAH?

Answer 9

Non-contrast CT scan

Question 10

What does the CT scan show?

Answer 10

Location of blood which helps localize site of ruptured aneurysm

Question 11

Why might a CT be negative?

Answer 11

Bleeding is slight or CT is delayed for several days

Question 12

What test must be performed to rule out SAH?

Answer 12

Lumbar puncture

Question 13

How long must you wait to perform a lumbar puncture? Why?

Answer 13

3-4 hours after symptom onset.
This allows RBCs in subarachnoid space to lyse and release hemoglobin in CSF. Helps determine between incidental blood from nicked spinal vein and hemorrhagic blood.

Question 14

How long after puncture must you wait to centrifuge the CSF if it is bloody/discolored? What are you looking for?

Answer 14

Immediately

xanthochromia

Question 15

How do you find location of SAH? Gold standard?

Answer 15

MRI for aneurysms > 5mm

4-vessel digital subtraction arteriography (DSA) for demostrating one or more aneurysms

Question 16

Most common causes of parenchymal hemorrhage?

Answer 16

Trauma (Most common cause)
HTN
Arteriovenous malformations

Question 17

What does HTN cause that lead parenchymal hemorrhage?

Answer 17

Microaneurysms called Charcot bouchard aneurysms that eventually rupture

Question 18

Where do HTN bleeds occur most frequently?

Answer 18

Basal ganglia (30%), thalamus (20%), pons (5%), and cerebellum (10%)