Hemorrhagic Stroke - Dr. Mucksavage (FINAL)

What is a subarachnoid hemorrhage?

Extravasation of blood into the subarachnoid space

What is an intracerebral hemorrhage?

Bleeding into the parenchyma of the brain

____% of all strokes are hemorrhagic.

13%

______% of hemorrhagic strokes are ICH.

77%

______% of hemorrhagic strokes are SAH.

23%

What are causes of SAH?

- Trauma

- Rupture of aneurysm

- Arteriovenous malformations

- Neoplasm

- Coagulopathy

- Unknown

What are causes of ICH?

- Spontaneous small vessel rupture

- Ateriovenous malformations

- Rupture of aneurysms

- Neoplasm

- Coagulopathy

What are modifiable aSAH risk factors?

- Hypertension

- Smoking

- EtOH abuse

- Sympathomimetic drugs (cocaine)

What are non-modifiable aSAH risk factors?

- Family history

- Women > men

- Mean age > 50

- Connective tissue disorders

What are modifiable ICH risk factors?

- Hypertension

- Smoking

- EtOH abuse

- Sympathomimetic drugs (cocaine)

- Anticoagulation: Maybe we are inducing ICH

What are non-modifiable ICH risk factors?

- Amyloid angiopathy

- Men > women

- AA, Asian > White

- Age (risk increases with each decade of life)

What are the signs and symptoms of hemorrhagic stroke?

- "Worst headache of my life" --> more prevalent in SAH

- N + V --> more prevalent in ICH

- Loss of consciousness

- Focal deficits

- Nuchal rigidity or neck pain --> more prevalent in SAH

- Seizures

- Elevated ICP

What diagnostic tests do we use to determine if the patient has a hemorrhagic stroke?

- Computerized tomography (CT) --> gives us general idea there is a bleed

- Lumbar punture (LP) --> might be useful if the CT is unclear

- Cerebral angiogram --> we can diagnose the precise location of the aneurysm

What is a cerebral angiography?

- Identifies source of bleeding

- Invasive

- Iodinated contrast is administered --> beware if the pt has contrast allergy or renal insufficiency

What should we do before administering iodinated contrast?

Make sure the patient is well hydrated using NS

What are the 2 classification/ grading scales for aSAH?

- Fischer Grading System (radiographic)

- Hunt and Hess Classification System (based on patient's symptoms)

What are surgical intervention options for aSAH?

- Craniotomy for clipping

- Placement of coils or glue

Ideally, initiate early (< 24 hours post-bleed)

What are medical management options for aSAH?

1) Reverse coagulopathy

2) Manage BP

3) Sedation (propofol, dexmedetomidine)

4) Analgesia (morphine, fentanyl)

5) Stool softener: docusate 100 - 200 mg PO BID-TID

6) VTE prophylaxis: heparin 5000 units SQ q 8 - 12H... 24H after aneurysm is secured

7) Antiemetics

8) Stress ulcer prophylaxis using H2RA or PPI

9) Maintain euvolemia + avoid hypotonic fluids (e.g. 1/2 NS or D5W)

What are reasonable antihypertensives to use when patient has aSAH?

- Labetalol (IVP)

- Nicardipine (infusion)

- Clevidipine

What drugs should be avoided in aSAH?

- Nitroprusside

- Nitroglycerin

*gives ppl a headache due to vasodilation, more blood goes to the brain, causing an increase in intracranial pressure

What is the only approved indication of Nimodipine (Nimotope, Nymalize)?

aSAH

What is the MOA of nimodipine?

DHP CCB, blocks calcium influx and vasodilates

What is the advantage of using nimodipine in aSAH? *EXAM

Decreases the neurologic deficits associated with vasospasm (but does NOT decrease incidence)

When should nimodipine be initiated for aSAH?

Within 24 hours of admission

What is appropriate dosing of nimodipine?

60 mg PO/NGT q4H x 21 days

*but if the pt develops hypotension, half the dose and half the frequency to 30 mg and q 2H

What dosage forms are available for nimodipine?

Capsule and oral solution

What is the only management strategy for ICH?

Medical management (same strategies as before)

How should warfarin coagulopathy be reversed?

- Phytonadione (Vitamin K1): 10 mg IVPB over 30 minutes

- KCentra (4FPCC)

What are some considerations when administering KCentra for warfarin coagulopathy reversal?

- Containers factors SN0T (seven, nine, 10, two)

- Contains small amounts of heparin and albumin (therefore, contraindicated in hx of DIC, HIT)

- ADRs include VTE

- Recheck INR in 30 minutes and every 6 to 8 hours for the next 24 to 48 hours

How is KCentra dosed?

- Inputs required: pre-treatment INR and weight

- Dosed by Factor IX units

IF INR < 2

10 - 25 units/ kg (max dose of 2500)

IF INR 2 - 3.9

- 25 units/kg (max dose of 2500)

IF INR 4 - 6

- 35 units/kg (max dose of 3500)

IF INR > 6

- 50 units/ kg (max dose of 5000)

How is reversal of dabigatran coagulopathy achieved?

Praxbind (idarucizumab)

*Kcentra is a reasonable alternative @ 50 units/kg

What is Praxbind dosing?

2.5 g IV over 5 min x 2 doses (2 consecutive infusions within 15 minutes)

How is reversal of rivaroxaban and apixaban achieved?

- KCentra @ 50 units/kg x 1 dose

- Activated charcoal if ingested within 2 hours

*andexxa no longer a thing!

Is seizure prophylaxis required in ICH?

No!

- Clinical seizures should be treated, but prophylaxis is NOT recommended

- If pt has unexplained depressed mental status, might be reasonable to conduct continuous EEG monitoring

How should blood pressure be managed in ICH?

- GOAL: SBP of 130 - 150 mmHg --> data says 140 mmHg is ideal but when are you ever going to be exact ...

- Initiate treatment within 2 hours to target BP in 1 hour (these patients are often presenting with high BP between 150 - 200 mmHg and you want to get this down bc they are at high risk for bleed)

- DO NOT try to go below 130 mmHg (HARMFUL)