| STROKE
1. Epidural hemorrhage
A. Ischemic (occlusive)
- Arterial/ venous in origin
- Typically a result of skull fracture
Acute ischemic strokes:
(penetrating trauma)
1. thrombotic stroke (clot) 2. Subdural hemorrhage
- commonly associated with atherosclerosis in - Cause: direct head injury
either intracranial or extracranial arteries 3. Subarachnoid hemorrhage (SAH)
- Common sites involved: bifurcation of the - More common
common carotid artery and the vertebral - Results from the bleeding into the
arteries at their junction with the basilar subarachnoid space (b/n pia mater
artery and arachnoid layers)
- Slow onset due to the gradual occlusion of - Usually due to RUPTURED ANEURYSM,
the arteries ARTERIOVENOUS MALFORMATION,
- Evolves over minutes to hours hypertension or trauma
2. embolic stroke (dislodge clot) ★ Aneurysm – abnormal
- Dislodged thrombus that travels to the ballooning of a normal artery,
cerebral arteries via the carotid artery or which usually develops in a
vertebrobasilar system weak spot on the artery wall
- Emboli can occur in patients with: (typically along: basilar
➔ nonvalvular atria fibrillation, artery, vertebral artery, or
➔ ischemic heart disease, superior cerebral artery)
➔ rheumatic heart disease, ○ Commonly are
➔ mural thrombi after a myocardial leaking aneurysm in
infarction, or the area of the circle
➔ insertion of a prosthetic heart valve of Willis
➔ Plaque that breaks off from the ★ AVM – uncommon
carotid sinus or internal carotid artery abnormality that occurs
- Most common site: MIDDLE CEREBRAL during embryonic
ARTERY (MCA) development; Tangled/
- Sudden development and rapid spaghetti-like mass of
occurrence of neurologic deficits malformed, thin-walled,
- Sx may resolve over several hours or a few dilated vessels; (common
days cause in young people)
- Sudden hemodynamic stress may result in 4. Intracerebral hemorrhage (ICH)
vessel rupture, causing bleeding within the - Mainly caused by uncontrolled/
brain tissue. severe hypertension
B. Hemorrhagic
, - Causes edema, distortion, and ➢ Unknown cause
displacement, which are direct ➢ May be d/t atherosclerosis (results in
irritants to the brain tissue a defect in the vessel wall with
- Occur more often with sudden, subsequent weakness of the wall),
dramatic blood pressure elevations Congenital defect of the vessel wall,
● CCA (CEREBRAL AMYLOID ANGIOPATHY) Hypertensive vascular disease, Head
○ Common cause in older adults trauma
○ Involves damage caused by the ➢ Any artery within the brain can be
deposit of beta-amyloid protein in affected, usually occurs at the
the small and medium-sized blood bifurcations of the large arteries at
vessels of the brain the circle of Willis
a. Primary ICH: due spontaneous ➢ Most commonly:
rupture of small vessels; ■ Internal carotid artery
b. Secondary ICH: due to: ■ Posterior communicating
- AVM artery
- intracranial aneurysm ■ Posterior cerebral artery
- intracranial neoplasms ■ Middle cerebral artery
(tumor formation)
- certain meds BP CATEGORIES
- anticoagulants like
coumadin, warfarin,
heparin, etc.
- amphetamines that
cause cerebral
vasculitis, which leads
to rupture
- Illicit drug use
MAIN CLINICAL MANIFESTATIONS
ISCHEMIC HEMORRHAGIC
Numbness Exploding headache
Weakness of face, arm ↓LOC
or leg (esp. In one side
of the body)
COMPLICATIONS OF HEMORRHAGIC STROKE
● Rebleeding
○ Highest during the first 2-12 hours
after initial hemorrhage
○ Sx: sudden severe headache,
❖ Intracranial (cerebral) aneurysm
nausea, vomition, ↓ LOC &
➢ Dilation of the walls of a cerebral
neurological deficit
artery that develops as a result of
○ Confirmed by a CT scan
weakness in the arterial wall
, ○ Surgery (surgical clipping) or ○ Subacute and delayed
endovascular coiling (less invasive) if ■ Gradual onset of drowsiness,
the pt is a candidate (if pt is stable) behavioral changes and
● Cerebral vasospasm ataxic gait
○ Narrowing of the lumen of the ■ Ventroperitoneal shunt/ VP
involved cranial blood vessel shunt
○ Frequently occurs 7-10 days after
initial hemorrhage, the clot
undergoes lysis and increases
chances or rebleeding.
○ Leads to increased vascular
resistance which impedes cerebral
blood flow and causes brain
ischemia and infarction
○ Monitoring using bedside
transcranial Doppler
○ Requires UTZ or follow-up cerebral
angiography
○ Intensified headache
○ ↓ level of responsiveness (confusion,
disorientation, lethargy) or evidence
of aphasia or partial paralysis
○ Nimodipine for prevention
○ Triple H therapy:
■ Hypervolemia
■ Induced arterial hypertension ● Seizures
■ hemodilution ○ Due to ↑ body temperature (in the 6
● Hydrocephalus cardinal signs of inflammation)
○ Blood in the subarachnoid space or ○ Maintain airway and prevent injury
ventricles impede the circulation of ○ Medications: Diazepam,
CSF, resulting in hydrocephalus carbamazepine
○ Acute hydrocephalus
■ sudden onset of stupor or
coma
● Hyponatremia
■ Managed with
○ After SAH forund in 10-30% of pt
ventriculostomy drain to ↓
○ Associated with the onset of
ICP
vasospasm
○ Monitor for hyponatremia
○ SIADH, cerebral salt-wasting
syndrome –volume depletion
○ Tx: IV hypertonic 3% saline (rapid
replacement of Na)
1. Epidural hemorrhage
A. Ischemic (occlusive)
- Arterial/ venous in origin
- Typically a result of skull fracture
Acute ischemic strokes:
(penetrating trauma)
1. thrombotic stroke (clot) 2. Subdural hemorrhage
- commonly associated with atherosclerosis in - Cause: direct head injury
either intracranial or extracranial arteries 3. Subarachnoid hemorrhage (SAH)
- Common sites involved: bifurcation of the - More common
common carotid artery and the vertebral - Results from the bleeding into the
arteries at their junction with the basilar subarachnoid space (b/n pia mater
artery and arachnoid layers)
- Slow onset due to the gradual occlusion of - Usually due to RUPTURED ANEURYSM,
the arteries ARTERIOVENOUS MALFORMATION,
- Evolves over minutes to hours hypertension or trauma
2. embolic stroke (dislodge clot) ★ Aneurysm – abnormal
- Dislodged thrombus that travels to the ballooning of a normal artery,
cerebral arteries via the carotid artery or which usually develops in a
vertebrobasilar system weak spot on the artery wall
- Emboli can occur in patients with: (typically along: basilar
➔ nonvalvular atria fibrillation, artery, vertebral artery, or
➔ ischemic heart disease, superior cerebral artery)
➔ rheumatic heart disease, ○ Commonly are
➔ mural thrombi after a myocardial leaking aneurysm in
infarction, or the area of the circle
➔ insertion of a prosthetic heart valve of Willis
➔ Plaque that breaks off from the ★ AVM – uncommon
carotid sinus or internal carotid artery abnormality that occurs
- Most common site: MIDDLE CEREBRAL during embryonic
ARTERY (MCA) development; Tangled/
- Sudden development and rapid spaghetti-like mass of
occurrence of neurologic deficits malformed, thin-walled,
- Sx may resolve over several hours or a few dilated vessels; (common
days cause in young people)
- Sudden hemodynamic stress may result in 4. Intracerebral hemorrhage (ICH)
vessel rupture, causing bleeding within the - Mainly caused by uncontrolled/
brain tissue. severe hypertension
B. Hemorrhagic
, - Causes edema, distortion, and ➢ Unknown cause
displacement, which are direct ➢ May be d/t atherosclerosis (results in
irritants to the brain tissue a defect in the vessel wall with
- Occur more often with sudden, subsequent weakness of the wall),
dramatic blood pressure elevations Congenital defect of the vessel wall,
● CCA (CEREBRAL AMYLOID ANGIOPATHY) Hypertensive vascular disease, Head
○ Common cause in older adults trauma
○ Involves damage caused by the ➢ Any artery within the brain can be
deposit of beta-amyloid protein in affected, usually occurs at the
the small and medium-sized blood bifurcations of the large arteries at
vessels of the brain the circle of Willis
a. Primary ICH: due spontaneous ➢ Most commonly:
rupture of small vessels; ■ Internal carotid artery
b. Secondary ICH: due to: ■ Posterior communicating
- AVM artery
- intracranial aneurysm ■ Posterior cerebral artery
- intracranial neoplasms ■ Middle cerebral artery
(tumor formation)
- certain meds BP CATEGORIES
- anticoagulants like
coumadin, warfarin,
heparin, etc.
- amphetamines that
cause cerebral
vasculitis, which leads
to rupture
- Illicit drug use
MAIN CLINICAL MANIFESTATIONS
ISCHEMIC HEMORRHAGIC
Numbness Exploding headache
Weakness of face, arm ↓LOC
or leg (esp. In one side
of the body)
COMPLICATIONS OF HEMORRHAGIC STROKE
● Rebleeding
○ Highest during the first 2-12 hours
after initial hemorrhage
○ Sx: sudden severe headache,
❖ Intracranial (cerebral) aneurysm
nausea, vomition, ↓ LOC &
➢ Dilation of the walls of a cerebral
neurological deficit
artery that develops as a result of
○ Confirmed by a CT scan
weakness in the arterial wall
, ○ Surgery (surgical clipping) or ○ Subacute and delayed
endovascular coiling (less invasive) if ■ Gradual onset of drowsiness,
the pt is a candidate (if pt is stable) behavioral changes and
● Cerebral vasospasm ataxic gait
○ Narrowing of the lumen of the ■ Ventroperitoneal shunt/ VP
involved cranial blood vessel shunt
○ Frequently occurs 7-10 days after
initial hemorrhage, the clot
undergoes lysis and increases
chances or rebleeding.
○ Leads to increased vascular
resistance which impedes cerebral
blood flow and causes brain
ischemia and infarction
○ Monitoring using bedside
transcranial Doppler
○ Requires UTZ or follow-up cerebral
angiography
○ Intensified headache
○ ↓ level of responsiveness (confusion,
disorientation, lethargy) or evidence
of aphasia or partial paralysis
○ Nimodipine for prevention
○ Triple H therapy:
■ Hypervolemia
■ Induced arterial hypertension ● Seizures
■ hemodilution ○ Due to ↑ body temperature (in the 6
● Hydrocephalus cardinal signs of inflammation)
○ Blood in the subarachnoid space or ○ Maintain airway and prevent injury
ventricles impede the circulation of ○ Medications: Diazepam,
CSF, resulting in hydrocephalus carbamazepine
○ Acute hydrocephalus
■ sudden onset of stupor or
coma
● Hyponatremia
■ Managed with
○ After SAH forund in 10-30% of pt
ventriculostomy drain to ↓
○ Associated with the onset of
ICP
vasospasm
○ Monitor for hyponatremia
○ SIADH, cerebral salt-wasting
syndrome –volume depletion
○ Tx: IV hypertonic 3% saline (rapid
replacement of Na)
