Hemorrhagic stroke

(series of slides used in class)

Classification Of Cerebrovascular Disease


  • Atherothrombotic
  • Lacunar
  • Cardiogenic embolic
  • Cause unspecified
  • Other


  • Intraparenchymatous
  • Sub-Aracnoideo

More than 85% of hemorrhagic stroke and 45% of ischemic are linked in some way with hypertension.

  • Serious damage to the artery wall (arterioesclerosis), with segmental dilatations especially in the territory of the middle cerebral artery and especially in the thalamus-striated.
  • Tortuous arteries and hard and soft plaques occur, which in turn can be complicated by obstruction or migration of elements from ulceration, He generating emboli away.

with??Hypertension prepares and cerebral hemorrhage â??

Frequently niques of ACV; the char- & shy; & shy sticas clini, generally correspond to the sudden appearance of any of the other & shy; following symptoms:

  • Weakness or clumsiness on one side of the body
  • Vision difficulty by one or both eyes
  • Unusual severe headache in patient
  • Dizziness or unsteadiness
  • Slurred speech and language disorders
  • Changes in sensitivity

Medical Conduct ACV:

  • Rapid neurological examination should be performed but complete.
    This should include: fundus and neck flexion.
  • The char- & shy; sticas clini & shy; Nicas infarct (ischemia) may be identical to the bleeding: the haemorrhage may be associated earlier with signs of intracranial hypertension; myocardial be identified clini & shy; & shy solely yes; ndrome corresponding to a specific vascular territory & shy; fico.

acute intracranial hypertension

  • Severe headache
  • Depression Awareness
  • Nausea and vomiting
  • Diplopia horizontal
  • Papilledema or retinal hemorrhages
  • Irritación changes & shy; ngea, Pain and stiffness in neck
  • Photophobia
  • Occasionally unilateral mydriasis associated even a third full torque (A aneurysm rupture. Posterior communicating)

Perform emergency CT

If depression of consciousness appears before 24 be suspected stroke hs:

  • Hemorrhage
  • Hypoxia
  • increased intracranial pressure
  • edema cerebral (large infarct)
  • brainstem commitment
  • crisis epiléptica

Hemorrhagic stroke

Risk factors (unchangeable)

  • Year Old
  • Sex
  • Constitution
  • Family history
  • Race

Risk factors (modifiable)

  • Hypertension (87%)
  • Diabetes (specially treated irregularly and discontinuous)
  • Obesity
  • Dislipidemias
  • Tobacco
  • Stress
  • Sedentary lifestyle

Other risk factors

  • Bleeding disorders and blood: intravascular coagulation, Disseminated, hemophilia, anemia drepanocí­tica, leukemia,reduced levels of platelets in the blood.
  • Use of aspirin or anticoagulant drugs (diluents Sangui & shy; neos)
  • Liver disease (is generally associated with increased bleeding risk)
  • Cerebral amyloid or brain tumors

Etiologic factors

  • Atheromatosis thalamo-capsular arteries
  • Arterial aneurysms pol & shy; gon Willis
  • Arterial aneurysms micoticos (secondary branches)
  • Malformaciones artery-venous
  • Vasculitis
  • Traumas
  • Discrasias sanguí­neas
  • Tumors
  • Anticoagulation
  • Use cake & shy; na

Forms CLI & shy; tech-

  • Login parenquimatosas
  • Subarachnoid
  • Mixed

ACV Login parenquimatoso

Affects fifth and sixth decades of life, evoke the classic â?? cerebralâ spill? , acute, fulminant, surprises the patient in full activity or effort, con hemiplejí­a, altered consciousness.
87% patients have a history of hypertension unknown, Untreated or poorly treated.

ACV Subaracnoideo

The variety of adolescents and young adults, eruption consists acute blood in the subarachnoid space, dominates the aneurysm ruptures pol & shy; gon Willis.
It starts with an acute headache fiercely with each other & shy; & shy ndrome Meni; NGEO, central vomiting, photophobia and rachialgia.

ACV Joint

It is a combination of the two previous forms and shapes are usually dumped into parenchymal intra subarachnoid space or AVMs.

Intracerebral hemorrhagic stroke

Table clini & shy; nico

Fulminant Table, agudí­simo (stroke) that surprises the guy in full swing, usually diurnal, with severe disorders of consciousness, hemiplejí­as facio braquio crurales, conjugate gaze palsy â??faces the injured? , etc.


  • Thursday the sixth decade of her life
  • Background of several years of hypertension
  • Day in full activity or effort
  • Acute onset, fulminant
  • Often initial headache
  • Blood pressure at admission
  • Altered consciousness
  • Deficit evident engine, hemiplejí­a facio braquio crural
  • Absence of trauma or poisoning


  • The Mayori & shy; to the intra-parenchymal hemorrhages are located in internal capsule and basal nuclei (75%)
  • Penetrating arteries injured by HTA: Putamen, Marriage bed, Protuberance, Cerebellum, Lobar (angiopatí­a amiloí­dea en ancianos).

Other locations are (25%):

  • Front: predominate confusion, psychomotor excitation, hallucinations, Engine biased focus attenuated (paresis) Motor apraxia
  • Parietal: hemiparesis with sensory disorders Disorders of consciousness asomatognosia less quantitative & shy; to
  • Occipitales: Contralateral homonymous hemianopia
  • Temporal Key: Aphasia
  • Brainstem: Severe alterations of consciousness, respiratory disorders Hemiplejí & shy; alternate as
  • Cerebellum: Consciousness disorders, Yes ataxia and ipsilateral limb loss & shy; ndrome intracranial hypertension due to obstructive hydrocephalus


ACV hemorragico

ACV hemorragico

ACV hemorragico

ACV hemorragico

If the CT shows intracerebral hemorrhage:

  • To determine the possible cause
  • Order Panangiografí & shy; if cerebral arteriovenous malformation or tumor is suspected
  • Request for urgent assessment Neurology & shy; & shy to neurosurgery; the
  • Order urgent assessment by UCI if Glasgow is 8/15 or less or if there is deviation li & shy; higher average nea 5 mm or decreased perimesencephalic tanks

ACHh IP – Initial Treatment

The best results are obtained when the patient is managed in a multidisciplinary and timely, remains essential to notice the specialist is as early as possible.
The key objectives are

  • Lifesaving
  • Mitigate the extent of brain damage
  • Prevent rebleeding
  • Prevent sequelae
  • Ensure basic functions: revival, cardiac massage, rescue breathing, suctioning intubation, etc.-
  • Channeling pluriorificial
  • Head to high 30 degrees
  • Symptomatic (analgesia, antipyretics, sedation)
  • Treating hypertension only if it exceeds 220 mmHg.
  • Evaluate referral center more complex. Especially if no impairment of consciousness, progression of neurological damage, anisocoria, Failure to control high blood pressure or breathing difficulties
  • Mannitol 15% delay before evacuation to a specialized center (100-150 cc to drip free)


The prognosis is generally grave (Almost mortality 50% to 48 hs.)

Is related to:

  • Locations of the injury (worse prognosis for deep, for trunk and dumped to ventra & shy; asses and / or produce hydrocephalus)
  • ± size or same
  • Serious disorder awareness (Mortality 90% income coma)with?Â
  • Intensity and duration of hypertensive crisis.

Subarachnoid stroke Hemorrágico (HSA)


The most important thing is to think about their existence

Be very careful to:

  • Moderate to severe headaches in people with acute onset young people
  • Headaches in which a neurologic compromise is detected even me & shy; nimo
  • In assign etiologà & shy; vacancies, as hepático origin or PSA & shy; quico
  • Sí­ndromes mení­ngeos mí­nimos

When in doubt an outpatient, perform symptomatic treatment and especially OBSERVE evolution, if the standard TAC doubts persist and if not possible lumbar puncture

If detection is Tardi & shy; ao retrospective should be advised immediately consult a specialist center with ambulance with the patient in absolute rest

Differential Diagnosis

1- With etiologi & shy; as infectious cause other & shy; & shy ndrome Meni; NGEO, especially purulent meningitis:

  • Sharper Initiation
  • Good condition prior health
  • Intense headache
  • No other & shy; ndrome infectious General
  • CT scan revealed blood in the subarachnoid space
  • Hemorrhagic CSF lumbar puncture

2- With producers boxes awareness deficit with or without focal neurological signs:

  • Spontaneous HIP: predominate signs of neurological deficit and severe disorders of consciousness, but no Yes & shy; & shy ndrome Meni; NGEO
  • Infectious processes, menningoencefalitis or abscesses: predominates septic, no hyperacute onset and sudden headache is not so marked and intensity, Antecedents missing
  • TEC: is the most frequent cause of subarachnoid hemorrhage, no signs of violence and trauma history

3- With benign headaches such as migraines and tension headaches

  • Chronicity and recurrence of cefaleico box
  • No stiff neck and spine, at most reduced mobility
  • Usually conflicts and stress
  • Frequent muscle contracture in other regions
  • No neurological compromise

HSA traumática con neumoencéfalo

Traumatic SAH with pneumoencephalus


  • Tomografí­a Axial Computarizada
  • Lumbar Puncture
  • Arteriografí­a de cerebral 4 vessels

Angio IRM angiografia angiotac

Angio TAC

Lumbar Puncture Indication

  • Table clini & shy; nico of Subarachnoid Hemorrhage without possibilities for tomografi & shy; a Computerized Axial.
  • Table clini & shy; nico suggestive of Subarachnoid Hemorrhage in the presence of inconclusive signs in tomografi & shy; a Computerized Axial.


Etiologí­a y Epidemiologí­a

  • The main cause of SAH is rupture of an intracranial aneurysm
  • Congenital arterial aneurysms are dilations due to congenital absence of the middle layer I embryological remnants, which usually are pedunculated and settle in their Mayori & shy; to the pol & shy; gon Willis
  • It is considered that among the 1 to the 2% of the population have this malformation (Autopsies); while the incidence of subarachnoid hemorrhage aneurysm is 10-20 patients 100.000 population per year
  • Predominates in the fourth and fifth decade of life, with slight female predominance 3:2

HSA Aneurisma

HSA traumatica

HSA aneurisma


HSA aneurisma

HSA aneurisma

angiografia comunicante posterior aneurisma

The widely predominant localization of intracranial aneurysms is in the circle of Willis, at the base of the skull and into the:

  • 33 % Cerebral-anterior communicating complex
  • 33 % Carotid Siphon
  • 33% Other locations

In Between 15-20 % have multiple aneurysms



  • On some occasions and given the growth of these birth defects can result neurological symptoms that are reminiscent of their presence
  • Since most settling in the circle of Willis are the most common cranial nerve deficits, especially the oculomotor
  • Another situation are incidental findings on the occasion of an imaging study performed for another reason; these patients should be referred to a specialist to evaluate the anatomical context, form, size, year old, overall, etc. and recommend a personalized treatment option

Medical Conduct

If the CT scan showed subarachnoid hemorrhage:

  • Hunt and Hess Scale
  • Scale Fisher
  • Order coagulation tests
  • Start Nimodipine IV 3 cc / h and increased to 5-8 cc / h lentamente monitorizando TAM
  • Start IV phenytoin (125 mg c/8 hs)
  • Request cerebral pan angiography
  • Order urgent assessment by Neurosurgery
  • Order urgent assessment by UCI if the Hunt and Hess is two or more or if Fisher is two or more

Hunt and Hess scale
(has prognostic value and guidance Treatment)with?Â

Escala de Hunt y Hess

Hunt and Hess scale

Scale Fisher
(To assess post vasospasm – HSA)

Escala de Fischer

Fischer scale

Treatment of Aneurysms

  • Clipped
  • Embolization


Aneurisma Clipado Embolizacion

Clipado de Aneursima

Early complications (0-3days)

  • Cerebral edema displacements
  • Resangramientos
  • Acute hydrocephalus
  • Cardiac dysrhythmias
  • Respiratory dysfunction
  • Pulmonary edema

Mediate complications (4-14 días)

  • Vasoespasmo
  • Rebleeding
  • Hipovolemia
  • Hyponatremia
  • Subacute hydrocephalus
  • Neumonía

Late complications (>15 días)

  • Chronic hydrocephalus
  • Neumonía
  • Pulmonary embolism
  • Rebleeding
  • Vasoespasmo cerebral
  • Disbalance hidroelectrolí­tico

Factors associated with rebleeding

  • Advanced age (> 70)
  • Días 0-1 Subarachnoid Hemorrhage
  • Poor neurological grading
  • Moderate or severe systolic hypertension (170-240)
  • Lumbar puncture in the presence of increased intracranial pressure
  • Ventriculostomy to relieve PIC
  • Associated with hypertension
  • Abrupt withdrawal of antifibrinolytic therapy
  • Abrupt intubation

Factors that predispose to vasospasm

  • Major bleeding that fill the basal cisterns
  • Días 4-14 after Subarachnoid Hemorrhage
  • Hyponatremia ( Cerebral salt-losing syndrome)
  • Hipovolemia ( Decreased blood volume or plasma)
  • Recurrent Subarachnoid Hemorrhage
  • Antifibrinolytic agents
  • Hypotension ( Decreased intravascular volume or pharmacologically induced)
  • Increased intracranial pressure
  • Other Ones ( Low cardiac output, disrritmias, hypoxia, anemias).

Roughly one 8-15% patients suffering from vasospasm in the first die 24 hours, without medical attention.

The mortality totals:

  • 20-25% in the next 48 hours
  • 44-56% in 14 Initial comings
  • 66% of 1-2 months after SAH



  • Recurrent bleeding; generally more severe than the initial, It is estimated between 3 and the 5% the annual risk
  • ï? Neurological deficit generated added by embolisms in the aneurysmal sac impact distance
  • Vascular occlusion of vessels where the aneurysm sits
  • Epilepsy partial or focal

With treatment

  • Depending on the seriousness of the starting box:
  • Dependent disorder initial awareness
  • Depending on the location and size
  • Experience specialist center
  • Experience traffickers neurosurgeons
  • Experience in the choice of therapeutic method

In Between 15-30% not reach the Hospital

deep coma initial: 87 % mortality with or without surger & shy; to

Incidental findings with cold treatment: 0,5% mortality and 2% morbidity

Hemorrhagic stroke Joint

Arteriovenous Malformations (MAV)

Bring together diverse malformations í & shy; Ndole:

  • true arteriovenous malformations
  • cavernomas
  • venous malformations
  • fi & shy; pustules dural arteriovenous
  • and capillary telangiectasias

AVMs are formed by a ball of dilated vessels that form an abnormal communication between the arterial and venous system, constituting an IF & shy; areriovenosa Sthula.

It is a developmental abnormality characterized by the persistence of an embryonic pattern vessels Sangui & shy; neos.







The lesion is present from birth, the beginning of each other & shy; symptoms usually occurs between 10 and 30 years old.

Recurrent Headache is a frequent complaint.

Can produce clini & shy; nica neurological through various mechanisms:

  • First breakdown may occur in the subarachnoid space, in Ventri & shy; asses brain, but it occurs most often in the brain parenchyma.
  • In the absence of bleeding, epileptic crisis, a progressive neurological defect develops as a result of a steal phenomenon of flow Sangui & shy; neo or as a result of a mass effect malformation.
  • Are shown in 0,1% population, prevalence 10 times lower than that of aneurysms
  • Are the 90% supratentoriales.
  • The average risk of bleeding has been evaluated in numerous studies of natural history, estimated in the 2-3% annual.
  • After a second hemorrhage risk of rebleeding may increase to 25%. The data clini & shy; mechanics and neuroimaging at the time of diagnosis can help predict the risk of future bleeding.

AVMs can bleed:

  • brain parenchyma (60%)
  • subarachnoid space (30%)
  • ventrí­culo (10%)


Clasificación de Spetzler - Martin

Rating Spetzler - Martin


  • Dependent risk factors dependent on the vital subject and factors related to the morphology, location and size of malformations.
  • The scale of Spetzler helps to assess the risk of surgery.
  • According to the overall assessment it can use the following approaches in isolation or in combination.


tratamiento mav

MAV - Embolización

MAV - Embolization



  • Recurrent bleeding (2-3% annual)
  • Progressive ischemia with increased neurological deficit (steal phenomenon)
  • Bruising intra parenchymal expansive
  • Obstructive hydrocephalus (Aracnoiditis reaction)
  • Status epilepticus

With treatment:

  • If evitan bleeding recurrences
  • Epilepsy: Partial seizures, gral. Easy Control
  • Possible increase in neurological deficit

Dr. Bernardo Sonzini Astudillo

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