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Haemorrhagic Stroke

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Overview

A stroke is a clinical syndrome characterised by clinical signs of focal or global neurological deficits due to an interruption in the blood supply to the brain. Strokes can be ischaemic or haemorrhagic. In a haemorrhagic stroke, there is sudden bleeding into the brain tissue.

Time is brain. It is essential to identify and manage strokes as soon as possible to reduce the risk of permanent neurological damage.

There are two main types of haemorrhagic stroke:

Epidemiology

  • Ischaemic strokes make up around 80% of strokes 
  • Haemorrhagic strokes make up around 20% of strokes 
  • Stroke is the 4th most common cause of death in the UK 
  • Strokes most commonly affect people >65 years but can happen at any age.

Causes

Primary intracerebral haemorrhage

There is no vascular malformation/associated disease:

  • Idiopathic
  • Hypertension – the most common risk factor
  • Anticoagulation

Secondary intracerebral haemorrhage

  • An acute ischaemic stroke
  • A cerebral tumour
  • Illicit sympathomimetic drugs such as cocaine and amphetamine:
    • These can cause hypertension
  • Arteriovenous malformations (AVMs):
    • These are direct arterial-to-venous connections without a capillary bed in between.

Risk Factors

  • Hypertension – the most common risk factor
  • Age
  • Arteriovenous malformations
  • Anticoagulant use
  • Coagulation disorders e.g. haemophilia
  • Heavy alcohol use
  • Illicit sympathomimetic drug use (cocaine/amphetamine)

Presentation

A stroke should be suspected in any patient with new-onset focal neurological symptoms. Some features may be:

  • Unilateral weakness or paralysis in the face, arm, or leg
  • Unilateral sensory loss
  • Problems with speech or comprehending speech
  • Visual changes
  • Headaches – sudden-onset and severe
  • Difficulties with coordination
  • Difficulties with gait
  • Vertigo or loss of balance

Although there is no way to reliably differentiate between ischaemic and haemorrhagic strokes based on symptoms, haemorrhagic strokes are more often associated with:

  • Seizures
  • Decreased levels of consciousness
  • Signs of increased intracranial pressure

Assessment

FAST

In the community, the FAST screening tool can be used:

  • Face – has their face fallen on one side? Can they smile?
  • Arm – can they raise both arms and keep them there?
  • Speech – is their speech slurred?
  • Time – time to call 999

ROSIER Score

After ruling out hypoglycaemia, the Recognition of Stroke in the Emergency Room (ROSIER) score can be used to assess patients in the emergency department. A score greater than 0 suggests a stroke:

  • Loss of consciousness/syncope: -1 point
  • Seizures: -1 point
  • New asymmetrical facial weakness: +1 point
  • New asymmetrical arm weakness: +1 point
  • New asymmetrical leg weakness: +1 point
  • Speech problems e.g. slurring: +1 point
  • Visual field defects: +1 point

Investigations

  • Capillary blood glucose:
    • To rule out hypoglycaemia which can mimic a stroke
  • Immediate non-contrast CT head:
    • To differentiate from an ischaemic stroke
    • Shows hyperattenuation (bright areas) suggesting blood
    • There’s often hypoattenuation (darkness) surrounding the hyperattenuation due to oedema
  • U&Es:
    • To rule out electrolyte disturbances which can mimic a stroke
    • To assess kidney function
  • LFTs:
    • To rule out liver disease as a cause of haemorrhage – significant liver disease can affect clotting
  • FBC:
  • Clotting screen:
    • To rule out coagulopathy, which may be a cause of haemorrhage
  • ECG:
    • To rule out cardiac ischaemia/arrhythmia
  • Serum and urine toxicology:
    • If toxic substance use suspected

Management

Overview

  • 1st-line: supportive care and monitoring + manage underlying cause
  • Offer rapid blood pressure (BP) control and aim for systolic ≤140mmHg if:
    • Within 6 hours of onset and BP is 150-220mmHg and
    • No underlying structural cause (e.g. tumour/AVM/aneurysm) and
    • Not having surgery to remove the haematoma and
    • Do not have a massive haematoma with a poor expected prognosis
  • Consider rapid BP control and aim for ≤140mmHg on a case-by-case basis if:
    • Within 6 hours of onset or systolic BP >220mmHg
  • Reverse anticoagulation if indicated:

Monitoring

  • Level of consciousness:
  • Blood glucose:
    • Keep between 4-11mmol/L
  • Blood pressure:
    • Monitor closely and manage, see above
  • O2 saturations:
    • Only start if saturations <95% or aim for 88-92% if the patient is at risk of hypercapnic respiratory failure
  • Hydration:
    • Assess regularly and maintain normal hydration
  • Temperature:
    • Give paracetamol if patients have a high temperature
  • Cardiac rate and rhythm:
    • Monitor regularly
  • Consider monitoring intracranial pressure (ICP) if:
  • Seizures:
    • Consult immediately with a neurologist and choose an anticonvulsant following local hospital protocol

Patient Advice

  • Patients should make lifestyle measures such as regular exercise, healthy diet, weight loss if appropriate, reduce alcohol intake, and stopping smoking
  • Patients and their family/carers should be offered advice on stroke and when to seek help and the principles of rehabilitation

Complications

  • Neurological complications e.g. balance/movement/sensation/tone
  • Associated haemorrhage in an acute ischaemic stroke
  • Seizures
  • Dysphagia
  • Cognitive impairment: aphasia/apraxia/visual agnosia/disinhibition
  • Visual impairments
  • Bowel and bladder incontinence/retention
  • Sexual dysfunction 
  • Pain: may be neuropathic and/or musculoskeletal
  • Psychiatric: depression/anxiety/changes in personality
  • Stress in carers

Prognosis

  • Mortality rates in haemorrhagic strokes are higher than in ischaemic strokes
  • Almost 2/3 of patients have a permanent disability after treatment
  • Around 1/4 of patients have a stroke again within 5 years
  • Around 1/2 of patients have residual neurological deficits

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