Nebres, Romarie P.

BSRT-2 May 9, 2020

Hemorrhagic Stroke

A. Patient Information: SCORE:26/50

CONTENT: 10/25 ORGANIZATION: 11/15
Demographics: MECHANICS: 5/10
COMMENTS: Discussion is insufficient with no attempt to patient correlate.
Similarly, the case lacks pertinent information given the multitude of cases
Patient: RM reviewed for Hemorrhagic Stroke.

Age: 81 years old

Gender: Male

 Chief complaint: headache, diaphoresis, dizziness, diplopia, sudden onset of right arm tingling,
numbness, and weakness, followed by progressive slurred speech
 History of present illness:
- Morning of the day he was admitted for emergency, he experienced headache, diaphoresis,
dizziness, diplopia, sudden onset of right arm tingling, numbness, and weakness, followed
by progressive slurred speech
Although, Stroke tends to be acute, your history is just too short to make sense.
 Medical History:
- Patient is hypertensive and has poorly controlled atrial fibrillation that was managed with
anticoagulant (so patient is Dyslipidemic as well) medications on a long-term basis
Antihypertensives?
 Family History:
- No Family history mentioned

B. Clinical Findings: (Physical Examinations)

 General appearance:
- RM was oriented, attentive, and cooperative, but his level of arousal fluctuated.
- Pupils were equal in size and reactive to light.
- Horizontal eye movements and conjugated gaze were severely restricted as a result of
bilateral abducent nerve paralysis.
- Vertical eye movements were normal and his jaw was deviated to the right.
- He showed bilateral facial weakness (right greater than left) and difficulties wrinkling the
forehead and closing the eyelids.
- He had severe dysphagia.
- His oral pharynx was dry.

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- His tongue and palate moved normally.

- His gag reflex was good.
- Respirations were of the Cheyne-Stokes type.
- Tactile discrimination and sensation of position of limbs were impaired on the left and intact
on the right.
- A distorted and heightened reaction to noxious stimuli was noted on the left.
- Bilateral segmental static reflexes were present.
- Deep tendon reflexes were decreased.
- Extensor plantar reflexes (Babinski sign) were negative.
- Verbal expression was difficult due to dysarthria.

C. Diagnostic Assessment

 CT Scan shows progressive hemorrhagic stroke intrinsic to the pontine tegmentum of the brain
stem, with rupture into the fourth ventricle.

D. Therapeutics, Patient Outcome and Follow-up

 Medical Treatments:
- Antidepressant medication (Zoloft* 100 mg/d) – to treat and/or avoid post-stroke depression
Assuming the location of patients stroke, does this correlate to potential depression
problem, hence is this immediately indicated? What level and location in the CNS regulate
emotions? Your patient have stroke in the pontine area and while it is progressive in nature,
it does not seem to atleast reach the basal ganglia/hypothalamus yet.
- Physical and occupational Therapy – To minimize fatigue
- Speech therapy – to Normalize speech
 Patient Outcome
- RM improved after 4 and a half month. He retained his comprehension, memory, judgment,
and problem-solving abilities after the stoke, however, he had another stroke and died due
to pneumonia complication
 Follow- up plan
- After the stroke, before he died (due to pneumonia) RM was required to participate in a
restorative program of exercise and ambulation designed to promote physical and mental
well-being.
- RM also received physical therapy, occupational therapy, and speech therapy from licensed
therapist for approximately 4 and a half months.

 Reference:

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- Ruhland, J., Kan P. (2003) American Physical Therapy Association: Medial Pontine
Hemorrhagic Stroke.Vol.83

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Nebres, Romarie P. BSRT-2 May 9, 2020

Part II. Discussion

A. Epidemiology

- Hemorrhagic Stroke is the second most common subtype of stroke and critical disease usually leading
to severe disability or death. It is more common in Asians, advanced age, male sex, and low- and
middle income countries, However, in some case, children may also experience stroke because there
are children who are born with blood vessel problems that can lead to hemorrhagic stroke.

- According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of
these, 5 Million die and another 5 million are left permanently disabled.

B. Pathology

 Cause of the disease

- Hypertension
- Aneurysm
- Diabetes
- Overweight
- Heart disease/disorder
- Coagulopathies
- Intracranial neoplasm

 Pathophysiology

Hypertension and other causes of Stroke

Lipohyalinosis replacing arterial musculature and weaken blood vessels.

Blood vessel ruptures and bleeds; Increase intracranial pressure

Blood Cytotoxicity and sudden focal internal brain trauma from hematoma mass effect

Clinical manifestations:

Neurological signs: Focal motor

General findings: Nausea, Respiratory
weakness, vision loss, sensory
vomiting, headache, symptoms/complications:
loss, imbalance/coordination,
seizures, lethargy Obstructive sleep apnea,
change in LOC
rapid breathing
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Nebres, Romarie P. BSRT-2 May 9, 2020

 Clinical Signs and Symptoms

- Weakness or paresis that may affect a single extremity, one half of the body , or all 4
extremities.
- Facial drop
- Monocular or binocular blindness
-Visual field deficits
- Dysrthria and trouble understanding speech
- Vertigo or ataxia
- Aphasia
- Sudden onset of severe headache
- Nausea
- Confusion or disorientation
- hand tremors
- frequent fluctuation in the heartbeat and breathing

C. Diagnosis

 Computed Tomography (CT) scan – Detects intracerebral hemorrhage and age of hematoma.
At onset, hematoma is commonly seen as uniform and smooth hyperintense signals on CT.
 Electroencephalogram (EEG) or lumbar Puncture ( spinal tap) – confirms the diagnosis of
hemorrhagic stroke

D. Treatment
* Medications used in the treatment of acute stroke:
- Anticonvulsants – to prevent seizure recurrence
- Antihypertensive agents – to reduce BP and another risk factors of heart disease
- Osmotic diuretics – to decrease intracranial pressure in the subarachnoid space
* After bleeding has stopped, surgery may also be done to help prevent a hemorrhage from happening
again and if patient is already out of danger, they must undergo rehabilitation to help them regain
strength, recover as much as function as possible.
* Therapy(Physical, occupational, speech) and medicine – to avoid depression and to monitor the
patient’s mental health.

 References:
- Liebeskind, D.(2019) Hemorrhagic Stroke Treatment and Management. Retrived from
https://emedicine.medscape.com/article/191662-treatment#d1
- WU, B. (2017) What to know about hemorrhagic stroke. Retrieved from
https://www.medicalnewstoday.com/articles/317111#causes

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