INTRACRANIAL HEMORRHAGE SECONDARY TO
RUPTURED LEFT MCA ANEURYSYM
Final Dx:
Intraparenchymal Hemorrhage Secondary to Ruptured Left
MCA Aneurysm
Parts of the Brain
Cerebrum
- largest part of the brain
- initiates and coordinates movement and regulates
temperature
Cerebellum
- “little brain”
- coordinate voluntary muscle movements and to
maintain posture, balance and equilibrium
Brainstem
- connects the cerebrum with the spinal cord
- houses the midbrain, pons and medulla
- Medulla - essential to survival.
o Regulates heart rhythm, breathing, blood
flow, and oxygen and carbon dioxide levels
Four Lobes of Cerebrum
Frontal Lobe
- controls eye and voluntary movement, executive
function (our ability to make decisions)
- Broca’s area – controls speech production
Temporal Lobe
- Long-term memory formation, hearing, smell
- Recognition of faces, scenes, and speech
- Wernicke’s area - in charge of understanding spoken
and written language
Aphasia
- Expressive aphasia (Broca) – they can understand
you, but they cannot express themselves
- Receptive aphasia (Wernicke) – they cannot
understand you, and often unaware of their spoken
mistakes
Parietal Lobe
- Sensory perception (interpreting pain and touch)
- Understanding spatial relationship (where one’s body
is compared with objects around the person)
Occipital Lobe
- Visual processing
Meninges
- Protective layers that surround the brain and the spinal
cord
- Dura mater – outer layer
- Arachnoid mater – middle layer, a thin, weblike layer
of connective tissue that does not contain nerves or
blood vessels
- Subarachnoid space – houses the CSF (a clear, watery
liquid that is pumped around the spinal cord and brain,
bathing them in nutrients and cushioning them from
impact)
- Pia mater – inner layer, hugs the surface of the brain
and follows its contours; is rich with veins and arteries
Cerebral Circulation
- The brain receives blood from the left and right internal
carotid arteries, as well as the left and right vertebral
arteries, which come together to form the basilar artery.
- The internal carotid arteries give rise to the left and
right middle cerebral arteries, which serve the lateral
portions of the frontal, parietal, and temporal lobes of
the brain; and also to the anterior cerebral arteries,
that nourish the medial portions of the frontal and
parietal lobes.
- The basilar artery gives off the right and left posterior
cerebral arteries, which mainly serve the occipital lobe
- The vertebral arteries and the basilar artery also give
branches for the cerebellum and brainstem.
Circle of Willis
The anterior cerebral arteries connect with one another
over a short connecting blood vessel called the anterior
communicating artery, while the internal carotid and the
posterior cerebral arteries connect through the posterior
communicating artery.
Together, the anterior and posterior cerebral arteries,
along with the internal carotids, the single anterior
communicating artery and the two posterior communicating
arteries form the Circle of Willis, which is a network of
anastomoses that allow uninterrupted blood flow to the brain
even when one of the vessels is obstructed.
INTRACRANIAL HEMORRHAGE
- Acute bleeding inside the skull or brain
Epidural hematoma
- between the skull bone and the outermost membrane
layer, the dura mater
- occurs after blunt trauma to the head (e.g., penetrating
head injury)
Subdural hematoma
- between the dura mater and the arachnoid membrane
- most commonly occur after a blunt head injury
Subarachnoid hemorrhage
- between the arachnoid membrane and the pia mater
- head trauma, aneurysms
- photophobia and nuchal rigidity (stiff neck caused by
blood irritating the meninges)
- (+) Kernig - flexes their legs at the hip and knee and
when the clinician extends them, pain is triggered
 - (+) Brudzinski - gently flexes the client's neck while the
client is lying flat and hip and knee flexion is triggered.
Intracerebral hemorrhage
- bleeding anywhere within the brain tissue itself
- Intraventricular - occurs in the brain’s ventricles,
which are specific areas of the brain (cavities) where
cerebrospinal fluid is produced
- Intraparenchymal - bleeding into the brain
parenchyma proper
Intraparenchymal Hemorrhage
Spontaneous rupture of damaged arteries account for 20%
of stroke cases for intraparenchymal hemorrhage, and is
associated with the highest mortality rates of all forms of
stroke (Guo, 2021).
This kind of intracranial hemorrhage occurs within the
brain parenchyma, the functional tissue in the brain consisting
of neurons and glial cells.
Neurons generate and propagate electrical and chemical
signals, whereas glia function mainly to modulate neuron
function and signaling.
It disrupts normal blood flow and subsequently deprives
the brain of oxygen. As a result, the brain cells can die, which
damages the affected nerves and the related functions they
control as well.
Clinical manifestations depend on the part of the brain that
is affected. For instance, middle cerebral artery (MCA)
aneurysms account for 20% of intracranial hemorrhage, and
affects the hands, arms, face, and the language centers in the
dominant hemisphere of the patient.
Left MCA – can cause numbness and sudden muscle weakness
on the right side of the body (hemiparesis), accompanied by
disorientation and personality changes.
- Hemiparesis is a mild or partial weakness or loss of strength
on one side of the body.
- Hemiplegia is a severe or complete loss of strength or
paralysis on one side of the body.
Additional clinical features can include signs of increased
intracranial pressure, such as decreased level of
consciousness, papilledema, increased blood pressure,
bradycardia, irregular breathing, as well as nausea and
vomiting.
ANEURSYM
Ballooning of an artery in the brain that can rupture and bleed
into the space between the brain and the skull due to weakened
areas of the blood vessel walls.
Most Common Sites:
- Anterior communicating artery
- Posterior communicating artery
- Middle cerebral artery
- Basilar artery
Aneurysms typically arise from bifurcations (branch points)
in the Circle of Willis because those areas of the vessels are
relatively weaker. (Note: Brain aneurysms develop as a result of
thinning artery walls.)
Risk Factors (present at birth)
• Inherited connective tissue disorders, such as Ehlers-
Danlos syndrome, that weaken blood vessels
• Polycystic kidney disease, an inherited disorder that
results in fluid-filled sacs in the kidneys and usually
increases blood pressure
• Brain arteriovenous malformation (AVM), in which the
arteries and veins in the brain are tangled, interrupting blood
flow
• Family history of brain aneurysm, particularly a first-
degree relative
PATHOPHYSIOLOGY
Predisposing Factors:
• Age – weakens the vessel wall
o Postmenopausal age group – risk is more
than twice as high
• Female –
o One study shows that women have
measurably smaller diameters of brain blood
vessels
o As a result, blood flow is faster and stress is
higher at the forks (bifurcation) of the middle
cerebral artery.
Blood Vessel Parts
All arterial vessels have three layers: from outside in, there’s
tunica externa or the adventitia layer, which has loose
connective tissue, and sometimes, vasa vasorum or vessels
that supply the artery;
Some huge vessels have tunica externa that is so thick that it needs
its own blood supply! So, there are tiny blood vessels, called the vasa
vasorum, which means “vessels of the vessels,” that creep along the
tunica externa to bring nutrients to that layer of the blood vessel wall.
Tunica media or the media layer, which contains some
elastic tissue and smooth muscle that allow the arteriole to dilate
or constrict in response to local conditions;
Endothelium, which consists of a single layer of endothelial
cells on top of a layer of connective tissue, called lamina propria.
In hypertension, the vasa vasorum can develop hyaline
arteriolosclerosis, narrowing their lumen, and causing ischemia.
This leads to atrophy of the smooth muscle of the tunica media,
and overall, weakening in the aortic wall.
The pathology of intracranial aneurysms starts when there’s
too much stress on the tunica media of the artery, which
weakens the vessel wall and allows blood flow to get turbulent.
This stretches the elastic lamina, as well as tunica externa, At GCS 8, we intubate
causing the blood vessel wall to weaken. And when this – endotracheal tube
happens, the blood vessel wall struggles to contain the pressure (ET tube)
of the blood pushing against the walls so the diameter of the
blood vessel lumen increases. Indications:
- To avoid aspiration
Intracerebral hemorrhage is more likely to cause sudden onset due to theoretical
headaches along with stroke-like symptoms with focal loss of protective
neurological defects depending on the location of the ruptured airway reflexes
aneurysm and the resulting ischemia.
- They cannot protect
their airway due to
Normal ICP: 5-15 mmHg
loss of gag reflex
- To avoid hypoxia
Glasgow Coma Scale
- used to objectively describe the extent of impaired
consciousness in all types of acute medical and trauma
patients
Hypoxia – low O2 in tissues
- GCS 9 (E2V2M5) >>> GCS 8 (E2V1M5)
Hypoxemia – low O2 in the blood

Mechanical Ventilation
A mechanical ventilator is a machine that helps a patient
breathe (ventilate) when he or she cannot breathe on his or her
own for any reason.

PHARMACOLOGY

Prior to Operation (GCS 9):

• Ampicillin-Sulbactam (Silgram) 1.5g IV loading dose
ANST then 750 mg IV q8h
o Penicillin and beta-lactamase inhibitors
o Antibiotic prophylaxis
o It works by killing the bacteria and preventing
their growth
• Omeprazole (Risek) 40 mg IV OD
o PPI
o Inhibition of gastric acid secretion in humans
• Mannitol 150 cc IV q4h
o Osmotic diuretic
o reduce cerebral edema and decrease ICP in
acute intracerebral hemorrhage
• Levetiracetam 500 mg IV q12h
o Anticonvulsant
o Prophylactic anticonvulsant use
o Decreases abnormal excitement in the brain

A sudden abnormal burst of electrical activity in the brain can lead

to the signals to the nerves being disrupted, causing a seizure. This
electrical disturbance can happen because of stroke damage in the
brain.

• Nicardipine drip 10 mg + 90 cc PNSS x 10 ugtts/min

= SBP: 130-140 mmHg
o Calcium channel blockers
o Acts by blocking the influx of calcium ions into
vascular smooth muscle and cardiac cells
during depolarization. This inhibition of calcium
flux results in a vasodilation and decrease in
cardiac work and oxygen consumption
o Lowers blood pressure (HTN)
Intubated (GCS 8):
• Citicoline 1 gm IV q12h
o pyrimidine ribonucleoside diphosphates
o psychostimulants and nootropics
o Prevent neuronal loss in the hippocampus,
decreased cortical contusion, and improved
neurological recovery
• Lactulose 30 cc ODHS
o Laxative
o Constipation; reduce strain when defecating
Post-op:
• Ketorolac 300 mg IV q1 for 3 doses ANST
o NSAIDs
o used to relieve moderately severe pain,
usually pain that occurs after an operation or
other painful procedure
• Paracetamol 1g IV loading dose then 60 mg SIVP q6h
o Analgesic and antipyretic
o Relieve post op pain
• Midazolam drip 25 mg in 500 cc PNSS x 0.5 mg/hr to
titrate +/- 0.5 mg to achieve RASS 0-1
o Richmond Agitation Sedation Scale mostly
used in the setting of mechanically ventilated
patients in the intensive care unit to avoid
over- and under-sedation
o 0 alert and calm, -1 drowsy, +1 restless
o Benzodiazepines (CNS depressant)
o It works by slowing activity in the brain to allow
relaxation and sleep
• Tranexamic acid 1g loading dose then 500 mg TID for
3 doses
o Antifibrinolytics
o inhibits fibrinolysis, promotes clot stability,
and may reduce inflammation
o reduce bleeding and transfusion
requirements
o controls bleeding, helps blood to clot
SURGICAL OPERATIONS
Craniectomy
- A craniectomy is a type of brain surgery in which
doctors remove a section of a person's skull.
Doctors do this surgery to ease pressure on the brain
that happens because of swelling or bleeding. They
leave the skull open until the pressure goes down, at
which point they close the opening in the skull.
- *In craniotomy, the bone is immediately replaced.
Evacuation of hematoma
- Aspiration to drain the blood
Clipping of aneurysm
- A small metal clip is used to stop blood flow into the
aneurysm
- The clip is placed on the neck (opening) of the
aneurysm to obstruct the flow of blood, and remains
inside the brain.
Tracheostomy (Sept. 10)
- A surgical procedure to create an opening in the
anterior trachea to facilitate respiration
- Most common: ventilator weaning for patients who are
unable to be liberated from mechanical ventilation.
- Prolonged ventilator dependence: Classic teaching
dictates tracheostomy be carried out 5-7 days after
endotracheal intubation in order to minimize the risk of
complications associated with long-term intubation,
most notable subglottic stenosis.
Tracheostomy tube
- Suctioning <10 seconds
- Suction OUT, never in.
Gastrostomy Tube (PEG)
- A feeding tube that is placed through the abdomen and
into the stomach
- Indicated for long term means of nutrition/hydration
- Preferred method of enteral feeding
- Dysphagia (difficulty swallowing) due to brain injury
- Decrease risk of pneumonia, especially in patients with
abnormal amounts of pooling secretions accumulation
Secretions are a natural reaction to tracheostomy, not a
sign of a problem. A trach tube bypasses the upper airway,
which normally cleans and moistens the air. This causes the
body to produce more secretions. When tracheostomy cuffs are
kept inflated for a prolonged period, these secretions can pool
in the airway.
CBG – 137-139 mg/dl (9/10-9-21) **highest
**Diabetes Type 2 is associated with an increase in intracerebral
hemorrhage. An increase in the glucose levels in the blood
causes hypertension, which is linked to the rise of hemorrhagic
stroke.
**Over time, excessive blood glucose can result in increased
fatty deposits or clots in blood vessels. These clots can narrow
or block blood vessels in the brain or neck, cutting off the blood
supply, stopping oxygen from getting to the brain and causing a
stroke.
PRESENT TIMELINE
Received patient on September 20, 2022, with O2 inhalation at
1 Lpm via tracheal mask, with gastrostomy tube, with heplock,
and with anti-embolic stockings on. GCS 11 (E4V1M6), moves
extremities mainly on the left side. Has sutured wound on the
left tempoparietal side of the head, both left and right extremities
have non-pitting edema, and grade 1 linear excoriation on
buttocks. Patient placed on egg crate mattress to prevent
pressure ulcer. Still on Nutribest 1600 kcal divided in 6 equal
feedings, and CBG monitoring BID.
Chest X-ray
→ Subsegmental atelectasis, right
o Collapse of a segment of the right lobe
happens when the lung sacs cannot inflate
properly, which means the blood may not be
able to deliver oxygen to organs and tissues
→ Magnified heart with left ventricular prominence
o Magnified or enlarged heart can cause fluid to
build up in the body and lungs, which can lead
to heart failure.
→ Atheromatous aorta
o Atheromas, or plaque buildups, in the aorta
obstructs blood flow. This is more likely to
happen if the patient have high blood
pressure.
→ Osteodegenerative Changes
o Degeneration or deterioration of bone tissue
due to aging.

Implementation + Rationales
Independent
1. Turn the patient every 2 hours.
o Turning mobilizes secretions and helps
prevent aspiration
2. Suction secretions as needed.
o Suctioning helps remove mucus
accumulation and maintain patent airway
3. Instruct patient to take several deep breaths before and
after suctioning.
o Hyperoxygenation before, during, and after
suctioning prevents hypoxia
4. Provide oral care every 4 hours.
o Oral care freshens the mouth after secretions
have been expectorated
5. Position patient in Semi-Fowler’s position as tolerated.
o To improve oxygenation and prevent
aspiration

Dependent
1. Maintain humidified oxygen as prescribed and check
the level as ordered. Ensure that the tracheal mask is
properly fitted.
o To reduce thickness and aid in the removal of
secretions

Collaborative
1. Carry out pulmonologist’s orders.
o To coordinate plans of care with regards to
the patient’s oxygenation status

+Drug Study