QUICK Stroke, Hemorrhagic

LESSON
Description/Etiology
Hemorrhagic stroke is a life-threatening medical emergency caused by hemorrhage
or rupture of an intracranial blood vessel. There are two forms of hemorrhagic stroke:
intracerebral hemorrhage (ICH), which refers to bleeding into brain tissue, and
subarachnoid hemorrhage (SAH), which refers to bleeding in the subarachnoid space
(i.e., the area between the middle membrane covering the brain and the brain itself, where
the cerebrospinal fluid [CSF] normally circulates). ICH is usually caused by rupture of
small penetrating arteries that supply deep structures of the brain (e.g., thalamus, putamen,
internal capsule) as a consequence of hypertension and cerebral atherosclerosis. ICH can
also occur after transformation of an acute ischemic stroke, after rupture of an arteriovenous
malformation (AVM) or an abnormal vessel that grows as part of a brain tumor, or as
a complication of the use of certain medications or drugs (e.g., oral anticoagulants,
thrombolytics, amphetamines, cocaine). SAH can occur as the result of hypertension,
trauma, or rupture of an AVM or intracranial aneurysm.
Hemorrhagic stroke causes brain injury and disrupts brain function through several
mechanisms including toxic effects of blood on brain tissue, hematoma formation
and expansion, cerebral edema, vasospasm, increased intracranial pressure (ICP),
hydrocephalus, and cerebral herniation.
Hemorrhagic strokes can be clinically indistinguishable from ischemic strokes, which are
caused by obstruction of cerebral blood flow due to a clot or embolism; however,profound
changes in level of consciousness (e.g., stupor, coma), elevated BP, symptoms of increased
ICP (e.g., headache, vomiting), and neck stiffness are more likely to occur in hemorrhagic
stroke than ischemic stroke (for more information on ischemic stroke, see Quick Lesson
ICD-9
431
About … Stroke, Ischemic ). Emergent brain imaging is needed to differentiate ischemic
stroke from hemorrhagic stroke and to identify complications. Differential diagnoses
includes migraine headache, meningitis, subdural hematoma, subarachnoid hemorrhage,
hyponatremia or hypernatremia, acute hypoglycemia, encephalitis, and brain tumors.
Authors
Tanja Schub, BS Treatment for hemorrhagic stroke usually begins with emergency department resuscitation
Cinahl Information Systems, Glendale, CA
and initiation of pharmacologic therapy (e.g., antihypertensives, analgesics). Patients with
hemorrhagic stroke andcoagulopathy may require vitamin K and prothrombin complex
Orna Avital, RN, BSN, MBA
Cinahl Information Systems, Glendale, CA
concentrate (PCC) or fresh frozen plasma (FFP) to reverse the effects of warfarin, protamine
Reviewers sulfate to reverse the effects of heparin, coagulation factor replacement therapy to correct
Eliza Schub, RN, BSN coagulation factor deficiency, or platelets to treat severe thrombocytopenia. Surgical
Cinahl Information Systems, Glendale, CA intervention can be necessary to treat the cause (e.g., aneurysm or AVM) or resolve
Sara Richards, MSN, RN complications (e.g., drainage of intraparenchymal hematoma, CSF diversion procedures for
Cinahl Information Systems, Glendale, CA
hydrocephalus). Management following the acute phase of a hemorrhagic stroke involves
Nursing Practice Council
Glendale Adventist Medical Center,
individualized rehabilitation regimens (e.g., physical, occupational, and speech therapy) and
Glendale, CA secondary prevention strategies (e.g., risk reduction through lifestyle modification of diet,
weight loss, and physical activity; pharmacologic treatment of hypertension and diabetes;
Editor invasive procedures [e.g., angioplasty, stenting in cases of arterial stenosis]).
Diane Pravikoff, RN, PhD, FAAN

Facts and Figures

Cinahl Information Systems, Glendale, CA

An estimated 795,000 people in the United States experience a new or recurrent stroke
June 12, 2020
each year; of these, about 10% are ICH and 3% are SAH. Incidence of ICH and SAH are

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25:100,000 and 10–14:100,000 per year, respectively. In 2016, hemorrhagic stroke was responsible for 2.8 million deaths
worldwide.The 30-day mortality rate in patients with ICH may be as high as 50%. In patients with SAH, the overall mortality
rate is 32–67%.

Risk Factors
Both atherosclerosis and hypertension increase the risk of cerebrovascular disease. Risk factors for hypertension include
smoking, obesity, high salt intake, stress, lack of physical activity, and family history of hypertension or stroke. Additional
risk factors for hemorrhagic strokeinclude anticoagulant therapy, coagulopathies, thrombolytic therapy for myocardial
infarction,intracranial vascular abnormalities (e.g., tumor, aneurysm), cerebral amyloid angiopathy, polycystic kidney disease,
systemic lupus erythematosus (SLE), pregnancy, acute alcohol intoxication, drug abuse (e.g., cocaine), migraine headaches,
advanced age, and a history of stroke.

Signs and Symptoms/Clinical Presentation

Patients with ICH usually experience sudden loss of consciousness and focal neurologic deficit. Vomiting, photophobia, pain
with eye movement, and severe headache, and seizures can also occur. ICH in the dominant hemisphere (usually left) can result
in right hemiparesis, right hemisensory loss, eyes deviated away from the side of the hemiparesis, and aphasia. ICH in the
nondominant hemisphere (usually right) can result in left hemiparesis, left hemisensory loss, and gaze deviated to the right.
Most patients with SAH develop a sudden-onset severe headache. They may also experience nausea and/or vomiting, visual
changes, loss of consciousness, seizures, nuchal rigidity, photophobia, and low back pain.

Assessment
› Patient History
• Ask about history of hypertension, stroke, cigarette smoking, trauma, and other risk factors from the family, and/or
previous medical records, if available
• Obtain information about the onset and progression of symptoms
› Physical Findings of Particular Interest
• Patient may be comatose or show signs of focal motor deficit or cerebellar or brainstem impairment, as altered mental
status or coma are more common with hemorrhagic stroke than with ischemic stroke
• A low Glasgow Coma Scale score (GCS; i.e., a test that measures motor response, verbal response, and eye opening, and
is based on a 15-point scale), which is associated with poor prognosis and a higher mortality rate. The GCS evaluates the
outcomes of brain injury, where 13–15 points indicate mild disability, 9–12 points indicate moderate disability, and 3–8
points indicate severe disability
• Conscious patients are likely to report severe headache
› Laboratory Tests That Can Be Ordered
• CBC, electrolytes, glucose levels, and coagulation study (e.g., prothrombin time [PT], activated partial thromboplastin time
[aPTT]) results may be abnormal
• Blood typing and screening can be necessary in the event blood transfusion is needed
• Serum alcohol level and toxicology screen may be ordered exclude alcohol and drug intoxication as possible etiologies
› Other Diagnostic Tests/Studies
• Noncontrast CT scan will differentiate between hemorrhagic and ischemic stroke and determine location(s) of hemorrhage
in patients with hemorrhagic stroke
• Head CT angiography may be ordered for high-risk patients if hematoma expansion is suspected
• MRI will identify small lesions; cerebral angiography or CT angiography can help to identify underlying AVM or
aneurysm
• ECG can detect atrial fibrillation
• EEG may be ordered to assess for seizure activity
• Lumbar puncture may be ordered to assess for blood in CSF

Treatment Goals
› Resuscitate, as Appropriate, Monitor, and Provide Intensive Supportive Therapy
• Assist with resuscitation, closely monitor vital signs and hemodynamic stability (e.g., central venous catheter [CVP] level,
ICP level), and assess all physiologic systems; elevate head of bed to 30° to decrease ICP; follow facility protocols for fall
risk and maintain patient safety (e.g., airway, circulation, and prevention of injury)
 –Monitor for and manage seizures, as ordered
• Confirm discontinuation of aspirin or anticoagulant therapy
• Administer prescribed blood products and medications, as ordered, which may include
–IV vitamin K, FFP, or PCC
–antihypertensive drugs (e.g., beta blockers [labetalol]) to control BP
–anticonvulsant medications (e.g., phenytoin)to prevent or control seizure activity
–osmotic therapy (e.g., IV mannitol, IV hypertonic saline) to decrease ICP (normal range of 7–15 mmHg)
–sedatives and muscle relaxants to reduce cellular metabolism and control muscle spasm
• Assess for pain and administer analgesic medication, as prescribed, to manage pain
• Monitor intake and output to maintain euvolemia; frequently assess level of consciousness and for headache/pain
• Assess for hyperthermia; control with prescribed antipyretics and/or sponge bath using lukewarm water mixed with alcohol
to maintain mild hypothermia (89.6–95 °F [32–35 °C])
• Provide deep vein thrombosis (DVT) prophylaxis using intermittent pneumatic compression
• Conduct or arrange for dysphagia screening before oral intake
• Follow facility pre- and postsurgical protocols if patient becomes a candidate for surgery; reinforce education and verify
completion of facility informed consent documentation (family member consent can be necessary)
› Provide Emotional/Psychosocial Support and Educate
• Assess patient and family member anxiety level and coping ability; educate and encourage discussion about stroke
pathophysiology, risk factors, prevention strategies, treatment risks and benefits, rehabilitation process, alterations to body
image/function, and individualized prognosis; request referral, if appropriate, to a
–social worker for identification of local resources for in-home services, rehabilitation programs, outpatient physical
therapy, or support groups
–mental health clinician for patient counseling on coping with a disabling condition or family member counseling for grief

Food for Thought

› Alzheimer disease may be a risk factor for hemorrhagic stroke. Authors of a recent systematic review evaluated eight studies
includinga total of 121,719 participants. They found that Alzheimer disease was associated with a 1.42-fold increased risk of
hemorrhagic stroke (Waziryet al., 2020)

Red Flags
› Worsening level of consciousness, unilaterally dilated pupils with absence of papillary light reflex, decerebrate rigidity,
and a deep irregular pattern of respiration are the signs of transtentorial herniation (i.e., increased intracranial pressure that
causes brain tissue to bulge from the cranium through the tentorial notch) and brainstem compression, which can be lethal
and require immediate intervention
› Anticoagulants and antiplatelet drugs are contraindicated in hemorrhagic stroke
› Monitor for acute hydrocephalus, which can necessitate ventricular drainage

What Do I Need to Tell the Patient/Patient’s Family?

› Strategies that reduce risk of stroke recurrence include strict adherence to the medical surveillance schedule and treatment
regimen; smoking cessation; alcohol reduction or avoidance; regular exercise; weight loss if overweight; and eating a
healthy, low-fat, low-sodium, high-fiber diet
› Seek immediate medical attention for new or worsening signs and symptoms of stroke

References
1. American Association of Neuroscience Nurses. (2012, December). Care of the patient with aneurysmal subarachnoid hemorrhage: AANN Clinical Practice Guideline Series.
Retrieved May 28, 2020, from http://aann.org/uploads/AANN_Aneurysmal_Subarachnoid_Hemorrhage.pdf
2. Bowman, L. (2018). Management of patients with cerebrovascular disorders. In J. Hinkle & K. H. Cheever (Eds.), Brunner & Suddarth's textbook of medical-surgical nursing
(14th ed., pp. 2009-2032). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
3. Connolly, E. S., Jr, Rabinstein, A. A., Carhuapoma, J. R., Derdeyn, C. P., Dion, J., Higashida, R. T., & Vespa, P. (2012). Guidelines for the management of aneurysmal
subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43(6), 1711-1737. doi:10.1161/
STR.0b013e3182587839
4. GBD 2016 Stroke Collaborators. (2019). Global, regional, and national burden of stroke, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016.
Lancet. Neurology, 18(5), 439–458. doi:10.1016/S1474-4422(19)30034-1
 5. Grasso, G., Alafaci, C., & Macdonald, R. L. (2017). Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives. Surgical Neurology
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8. Khan, A. B., Goldsmith, C., & Krishnamohan, P. (2020). Stroke, hemorrhagic. In Ferri’s clinical advisor 2020 (pp. 1310-1312). Philadelphia, PA: Elsevier.
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