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1.02C Hemorrhagic Stroke  Neuroprotective measures (permissive hypertension,
Dr. John Harold Hiyadan/ January 24, 2018
PRELIMS; QUIZ NO. 1
Red bold- emphasized during lecture, Blue italic- Audio, Green-OT/ book
Cont. of Ischemic Stroke:
MANAGEMENT OF ACUTE ISCHEMIC STROKE
 Admission to Acute Stroke Unit
o increases the odds of better functional outcome
compared to those admitted at the general ward
o Acute Stroke Unit - specialized area where health care
workers are very well trained to treat stroke patients
o Ideally, stroke patients should be admitted at the
stroke unit
 Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is
recommended for selected patients who may be treated
within 4.5 hours of onset of ischemic stroke
o Recombinant Tissue Plasminogen Activator
(rtPA) - lyses the blood clot by lysing the fibrin
o we have natural tPA in our body but is not enough
during thrombotic state that is why we give exogenous
tPA
o number 1 objective is to remove the clot and recanalize
the blood vessel to stop the ischemic cascade from
progressing so that Ischemic Penumbra will not turn
into Ischemic Core
o given the earlier the better habang wall pang ischemic
core - better outcome
o habang tumtagal, your ischemic core mas lumalaki if
you do not reperfuse
o cannot be given if more than 4.5 hours from onset
 Mechanical Thrombectomy within six hours from
the onset of stroke
o insert a cannula, catheter or wire from the femoral
artery to the heart then to the brain
o “plumbing”
 Oral administration of Aspirin (initial dose is 325 mg)
within 24 to 48 hours after stroke onset is
recommended for treatment of most patients
o given if patient is not qualified to receive rtPA and
undergo mechanical thrombectomy
 With cardioembolic stroke (red clot) treatment with
Warfarin is an option to prevent early recurrence of
stroke
o NOT due to valvular atrial fibrillation
o better than aspirin
o Atherothrombotic clot - white clot
 Surgical decompression with Hemicraniectomy is
recommended to increase chance of survival of patients
with large/malignant cerebral infarction
o more than 2/3 of half of your brain
o very severe stroke
o surgeon does duraplasty to release the pressure
o large malignant infarct - mortality is about 80%, 20%
chance of survival
 Osmotic agents (Mannitol, Hypertonic Saline)
should be instituted to patient with large infarcts
producing increased intracranial pressure
o to reduce the pressure
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TRANSCRIBERS: BAI, C. I MICHAEL, H. Page 1 of 2
NEUROLOGY 2
normothermia, normoglycemia, hydration)
o may save your ischemic penumbra
o fate of your ischemic penumbra depends on the
recanalization of your vessels and collaterals
o avoid drop in blood pressure
o lower the MAP by only 20% using Nicardipine
drip for the next 24-48 hours
o Permissive Hypertension
Criteria:
 if the MAP is more than 130, that is when we can
give titrable agents to lower blood pressure
 if MAP is 130 and below, do not touch the
blood pressure
 if systolic is more than 210, lower the BP
 if diastolic more than 110, lower the BP
 if BP doesn’t fulfill criteria, do not touch the BP
o Contraindications for Permissive Hypertension:
Acute MI, Acute Renal failure and CHD
o Normothermia: avoid fever - an independent risk
factor in ischemia
o Normoglycemia: maintain blood sugar below
160mg/dL because hyperglycemia is an indicator of
poor outcome
o Hypoglycemia can mimic stroke (tutulog tulog ang
pasyente, common ddx)
o Hydrate the patient using 0.9% NSS
- avoid dextrose containing water to avoid
hyperglycemia and can cause cerebral edema
- improves circulation to the brain
 Neuroprotective drugs (ex. Citicholine, Piracetam,
Cerebrolysin, NeuroAiD)
o lots of neuroprotective drugs used in clinical trials fail
o intervene in the cascade to prevent further damage in
the brain
o Citicoline - stabilizes the membrane, trend in clinical
trials is towards improvement but is not significant
o NeuroAiD - traditional Chinese medication, was almost
significant
HEMORRHAGIC STROKE
 30% of stroke (American Stroke Association: Ischemic
Stroke: 87%; Hemorrhagic Stroke: 13%)
 Intracerebral > Subarachnoid Hemorrhage
 Usually occurs during stress or exertion (for
example, it may occur in patients carrying a bag of
cement, running, at work or confronted by a stressful
situation. If it occurs during sleep, it is less likely
hemorrhagic. Patient’s activity/environment during the
attack is important in the history of a patient with
stroke)
 Focal deficits rapidly evolve
 Confusion coma or immediate death
o if hematoma is large
 DO NOT do Permissive Hypertension in
hemorrhagic stroke
INTRACEREBRAL HEMORRHAGE
 Hypertensive hemorrhages are usually located deep in
the basal ganglia, putamen, thalamus, and brainstem
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 Lobar/superficial hemorrhages may not be related
to hypertension but with other blood vessel disease
(Amyloid Angiopathy of the elderly)
 Classic presentation: sudden onset of headache, vomiting,
very high blood pressure, focal neurologic deficit may
present with agitation and lethargy then progresses to
stupor and coma
 pag nagbleed kasi yan, pag nag expand yung hematoma,
madedepress and sensorium
 categorized as small vessel disease
 result of a chronic hypertension
NEUROLOGY 2
PRACTICE QUIZ:
1. Recommended treatment for patients with
ischemic stroke within 4.5 hours of onset.
2. Mechanical thrombectomy should be done
within __________ from the onset of stroke.
3. IV fluid of choice in hydrating a patient with
stroke.
4. Citicoline, Piracetam, Cerebrolysin and
NeuroAiD are collectively called _____.
5. Aneurysm of penetrating arteries associated
with chronic hypertension.

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CHRONIC HYPERTENSION
 Produces a small vessel vasculopathy characterized by
Lipohyalinosis, Fibrinoid necrosis
 Development of Charcot-Bouchard Aneurysms, affecting
penetrating arteries (small blood vessels/microaneurysms)
o It is different from saccular aneurysms that causes
subarachnoid hemorrhage
o Charcot-Bouchard Aneurysms are not associated with
subarachnoid hemorrhage
 Predilection sites for Intracerebral Hemorrhage includes:
o Basal Ganglia (40-50%)
o Lobar Regions (20-50%)
o Thalamus (10-15%)
o Pons (5-12%)
o Cerebellum (5-10%)
o Other brainstem sites (1-5%)
MANAGEMENT OF INTRACEREBRAL HEMORRHAGE
 Aggressive BP control to prevent early hematoma
expansion is recommended (SBP <140 mmHg)
 There were clinical trials that came out where patients with
BP: <140mmHg vs. BP: 180mmHg showed no significant
difference in hematoma expansion. Although current
guidelines recommend SBP <140mmHg.
 Medical decompression with osmotic agents (Mannitol,
Hypertonic Saline) is recommended in patients with signs of
increased intracranial pressure
 Size of hemorrhage also matters in the management: ICH
greater than 3cm/30cc causing neurological
deterioration should be evacuated surgically
 Take note of the qualifier “neurological deterioration”. If the
patient has 30cc hemorrhage but has no neurological
symptoms, then I won’t operate. However, if there are
neurological symptoms, then do surgery.
 Young patients with moderate large lobar hemorrhage
are clinically deteriorating and should be surgically
managed

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TRANSCRIBERS: BAI, C. I MICHAEL, H. Page 2 of 2