04.02 Hemorrhagic Stroke (CVA)

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Hemorrhagic Stroke Risk Factors (Mnemonic)
Stroke Pathochart (Cheat Sheet)
Intraparenchymal Hemorrhage (Image)
Cerebral Aneurysm (Image)
Coiled Aneurysm (Image)
Pureed Diet (Image)

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So let’s look specifically at hemorrhagic stroke. We’re going to talk about the pathophysiology and major points, then we’ll talk about assessment, therapeutic management, and nursing care in a later lesson.

A hemorrhagic stroke is a lack of blood flow to the brain tissue caused specifically by a bleed somewhere in or around the brain. Typically this occurs because one of the blood vessels in the brain has ruptured. In the cardiac course we talk a lot about hypertension and how much it can weaken those blood vessels, same with aneurysms. You can have these weakened blood vessels and weakened outpouchings in the brain as well. When one of them ruptures, blood flow beyond that spot is severely diminished. No blood flow, remember, always leads to death of the tissue. It’s like trying to water your flowers when there’s a hole in the side of your hose. So not only do we lose blood flow, but now we start building up blood where it doesn’t belong - and if you remember from the ICP lesson, that’s going to increase our intracranial pressure. In addition to other neurological symptoms of stroke that we’ll look at in the assessment lesson, these patients often complain that this is the worst headache of their life, sometimes it even wakes them out of their sleep. When we do a CT scan, we will be able to see immediately that there is bleeding on the brain, like you can see here.

Risk factors for hemorrhagic strokes, again hypertension is a huge one as well as substance abuse, specifically cocaine use. Both hypertension and cocaine will weaken these vessel walls until they burst. We also need to consider anyone on anticoagulant therapy as being at risk - especially our little elderly patients who are on warfarin for their A-Fib, but also are losing their balance a lot - if they fall and hit their head, it could cause damage to the vessels and lead to a hemorrhagic stroke - especially because their body is not clotting like it should.

There are a couple of complications that are high-risk in a patient with a hemorrhagic stroke and they both relate to the fact that blood, when it is somewhere it’s not supposed to be, is very irritating. Keep that in mind for the whole body, not just the brain - blood is an irritant. Now, remember we have our brain tissue and it’s covered by the Pia mater. Then we have our skull which is lined by the dura mater. And in between we have the arachnoid layer. Underneath this, in the subarachnoid space, there are tons of nerve endings. This is also where the majority of our major blood vessels are within the skull. If you start to get blood in this space, it’s going to irritate those nerve endings and those blood vessels. So you can see seizures as well as vasospasm. Vasospasm is when the blood vessels in the brain spasm or clamp down. So now, not only do you have the issue of the bleed, but now you’re getting ischemia because the vessels have clamped down. And 3 days after the stroke, you’ll suddenly see the patient develop new stroke symptoms. So you'll see in the therapeutic management lesson the things that we do to mitigate these risks.

So just to recap, a hemorrhagic stroke is a lack of blood flow to the brain due to bleeding. Some modifiable risk factors are hypertension and substance abuse because of their effect on weakening the blood vessels. We need to be cautious with patients who are on anticoagulants, especially the elderly who are prone to Falls. And we need to take precautions to prevent complications like seizures and vasospasm.

Make sure you check out the rest of this module to learn more about how we manage stroke patients. In the nursing care lesson you'll find a detailed care plan as well as a case study, so be sure to check that out. Now go out and be your best selves today. And, as always, happy nursing!
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