Stroke vs aneurysm

Austin carawan

Austin carawan

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ive narrowed it down to these two, the patient has the worst headache of her life, with rapid onset, and blurred vision, and her left arm is weak,(tell tail stroke sign right?) she feels nauseous and her speech is slurred,are there any findings in stroke not seen in an aneurysm l, and vice versa, either way transport is indicated. But with mainly book experience on these two they appear similar in their symptoms
 
What is a stroke? Starting from here will make things clear.
 
When blood flow to the brain is interrupted a stroke occurs. This causes the loss of brain function due to the absent oxygen delivery
 
And what kinds of strokes are there?
 
Ischemic-clot
Hemorrhagic- freely moving blood clots in brain, basically squeezing brain tissue next to it
Transient ischemic- self resolving or ministroke
Different symptoms shown on left and right sides
 
You got the two groupings of stroke down: ischemic and hemorrhagic. It's not all clots though.

Ischemic stroke is caused by a group of problems that involve the narrowing or blockage of cerebral blood flow, this includes clots, but also can involve fat, air, stray bullet fragments, etc.
Hemorrhagic stroke simply involves some sort of bleeding within the passages of the brain, whether it be the subarachnoid space (one of the thicker exterior layers), or the intracerebral portion (the interior channels).
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Very neat, now let me ask you this, if fat, or bullet fragment is causing the clot, a thrombolitic clot buster assuming it's indicated would thus be rendered useless correct? How could you treat that? Besides monitoring pulse ox and haulin tail???
Flying said:
You got the two groupings of stroke down: ischemic and hemorrhagic. It's not all clots though.

Ischemic stroke is caused by a group of problems that involve the narrowing or blockage of cerebral blood flow, this includes clots, but also can involve fat, air, stray bullet fragments, etc.
Hemorrhagic stroke simply involves some sort of bleeding within the passages of the brain, whether it be the subarachnoid space (one of the thicker exterior layers), or the intracerebral portion (the interior channels).
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Austin carawan said:
Very neat, now let me ask you this, if fat, or bullet fragment is causing the clot, a thrombolitic clot buster assuming it's indicated would thus be rendered useless correct? How could you treat that? Besides monitoring pulse ox and haulin tail???
Click to expand...
I don't know much about thrombolytics, but I do know they are very effective in any case that they are given, and that the patient must be screened carefully.
TPA obviously wasn't designed for lead or fat, but it doesn't care, you will still shoot down the clotting factors in that person.

As for the BLS end of treatment, it comes down to wearing your seatbelt, giving oxygen, having a convincing report ready, and praying that the person is okay.

Stroke, or suspected stroke is one of the conditions that you just don't F with. You need xrays, and you need expertise.
 
Haha, I'm with ya man. Is a stroke more serious than an aneurysm? Or do they both yield a fairly equal concern in their respective causes?
 
What is an aneurysm?
 
Austin carawan said:
Swelling of a part of a blood vessel, I believe because the wall gets weak, and I know they have the potential to rupture,
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Correct. The ballooning of the vessel will often be asymptomatic and go completely unnoticed. When it ruptures is when you see the problems. And once the aneurysm ruptures, it's synonymous with hemorrhagic stroke. So stroke = ruptured aneurysm. Thus why they have such similar symptoms.
 
That's makes complete sense, basically, an aneurysm=underlying condition
Ruptured aneurysm= hemorrhagic which is emergency, awesome, thank you all!
 
Austin carawan said:
are there any findings in stroke not seen in an a by pressneurysm l, and vice versa, either way transport is indicated. But with mainly book experience on these two they appear similar in their symptoms
Click to expand...

As above, a ruptured aneurysm is going to cause a hemorrhagic stroke. However, a large unruptured aneurysm could cause subtle and less-subtle neurological symptoms by pressing on the brain in a specific location. Paroxysmal headaches, vision changes, paresthesias, weakness, etc could give away an unruptured aneurysm. Something you could consider asking about if someone on scene knows the patient well.
 
Hmm, would there be anything that would make one successive to an unruptured aneurysm? Also, would that patient be emergency transport?
 
Should I be thinking about hemorrhagic strokes the same way that I would think about a cerebral hemorrhage caused by trauma? Or are there fundamental differences?
 
I guess if you want to get picky a haemorrhagic stroke is just a sub-type of intracerebral bleeding.

Yes, stroke is an emergency There continues to, generally, be contentious debate regarding the appropriateness of thrombolysis for ischaemic stroke Last I heard, the Australasian College for Emergency Medicine was not overly supportive of the idea. In order to be a candidate for stroke thrombolysis, a patient must be treated within 3.5 hours, noting this varies a wee bit depending on which guideline you read. Ischaemic vs haemorrhagic stroke cannot be diagnosed without access to a CT scanner, hence the "sense of urgency" attached to getting the patient to a CT-and-thrombolysis capable hospital if they were "last seen normal" within the time frame.
 
An ischemic stroke is caused by a clot from somewhere in the body making its way into on of the vessels in the brain and causing a blockage of that vessel. This leads to ischemia of the portion of the brain served by that vessel.

An aneurysm is a ballooning in the wall of a blood vessel. Think of the ballooning in the wall of a garden hose when you block one end. As others have said, the aneurysm can be asymptomatic or if it is pushing on something it can be symptomatic. They can also rupture, leading to bleeding into the brain. This is a hemorrhagic stroke. Most aneurysmal bleeds are in the subarachnoid space. The issue in this case is not a clot but bleeding.

Hemorrhagic strokes can also be caused by trauma. These bleeds are usually intraparenchymal, subdural or epidural.

Fat emboli and bullets are usually caused by trauma and trauma is one of the absolute contraindications to thrombolytics. Thrombolytics are only useful for ischemic strokes because they break down the clot in the vessel. This is all in theory and the evidence is sketchy.
 
So excited to be talking about the brain!!

You guys are right, there are ischemic strokes and hemorrhagic strokes. But you need to further subdivide the hemorrhagics based on where they occur. A bleed into the brain parenchyma is a very different animal that a bleed into the subarachnoid space. Non-traumatic parenchymal bleeds tend to occur in elderly patients with hypertensive vascular disease and usually involve the deeper structures of the brain. Generally we do not intervene on these bleeds, but instead provide supportive care.


But let's talk briefly about the subarachnoid hemorrhage. Hopefully I can bring this a little more full-circle for you guys than I ever got in my EMS years.

Non-traumatic subarachnoids usually occur due to aneurysm rupture. These are the patients who "died of an aneurysm in the brain."

They frequently occur at branch points on the circle of Willis, the circle of arteries which sit in a pool of CSF at the base of the brain. When the aneurysm ruptures, blood leaks into the CSF and we can usually see blood on a regular CT, active bleeding on a CT-Angiogram or can see blood in the CSF on a spinal puncture.

This is the "thunderclap headache" you learn about in school. Sudden onset, "worst headache of my life" usually with lots of vomiting and frequently altered level of consciousness. The blood in the subarachnoid space (which I encourage everyone to google and understand where this actually is) is very irritating to the brain. They may go unconscious, they may seize, and often the brain will swell because it is so irritated.

If they swell, we will put a ventricular drain in and if the pressure is still out of control after a drain and medical therapies, we take the skull off and allow the brain to swell.

The important part of a subarachnoid bleed versus other types of strokes is the potential for vasospasm. The blood in the CSF irritates the vasculature too and for about 10-15 days after the original bleed, the brain vasculature may randomly spasm, leaving areas of the brain with no blood flow. So, it literally looks like an ischemic stroke and we have to take them down to the angiography suite and re-open the artery either with drugs or balloons, or both. And some patients do this multiple times in their post-bleed period.

Overall, you see subarachnoids in a younger population. Which is also good because younger brains tend to do better in terms of long-term outcome.

Unfortunately, severe bleeds with lots of vasospasm usually leave a patient with minimal function, a PEG and trach and shipped to a long term care facility, regardless of age.

If you want to learn more about the size of the bleeds and the link to long-term outcomes, check out the Hunt & Hess scale and the Modified Fischer Score.

But overall, though subarachnoid bleeds and intraparenchymal bleeds are both hemorrhagic strokes, they effect very different populations and generally have very different medical course.


Think about a SAH in younger patient with sudden loss of consciousness with nor recovery, usually some type of abnormal respirations and no other obvious cause for loss of consciousness. Prehospital, the focus should be on maintaining or securing that airway. This is another group that will vomit and aspirate at the drop of a hat.
 
A good, quick tool for subarachnoids is keurnig's sign, which is "guarding" with the legs (much like in abdominal injuries) with neck flexion. As a rule of thumb subarachnoids will present much like afebrile Meningitis, outside of history taking.
 
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