0071643192.pdf

DIFFERENTIAL

■ Hypoglycemia, Todd paralysis, complicated migraine, mass lesion, delirium

DIAGNOSIS

■ Suspect based on history and examination.

■ Confirm by noncontrast CT scan (Figure 15.3).

■ Lumbar puncture is necessary to rule out subarachnoid hemorrhage,

when suspected.

TREATMENT

■ Supportive therapy

■ Elevated head of bed to 30º

■ Hyperventilation (to PaCO 2 of 30), mannitol and furosemide if impending

herniation

■ Hypertension

■ Treat if severe (>220/120 mmHg) with goal of gradually lowering BP to

prehemorrhage levels

■ Use titratable agent—labetalol or nitroprusside.

■ Seizure prophylaxis with phenytoin

NEUROLOGY

TABLE 15.4. Hemorrhagic Stroke—Neurologic Findings

LOCATION NEUROLOGICFINDING

Putamen (most common) Contralateral hemiplegia

Contralateral sensory deficits

Contralateral conjugate gaze paresis

Homonymous hemianopsia

Aphasia, neglect, apraxia

Usually more lethargic than middle cerebral infarcts

Cerebellar Severe ataxia, vertigo, nystagmus

Dysarthria

Decreased LOC (may occur)

Ipsilateral gaze palsy, facial weakness and sensory loss

NO hemiparesis

Thalamic Contralateral hemiparesis

Contralateral sensory deficits

Sensory loss > motor loss

Pontine Severe headache

Hyperventilation

Pinpoint pupils

Absence of oculovestibular reflexes

Decerebrate posturing