The Pressure Cooker: Hypertension and Hemorrhagic Stroke

The Pressure Cooker: 

Hypertension and Hemorrhagic Stroke 

Darlene Bowman, RN, CNN(C) 

Nicole Chenier-Hogan, BNSc, MSc, APN, 

CNN(C) 

Delanya Podgers, BSc., RN, CNN(C)

Objectives 

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Review prevalence and pathophysiology of 

hypertension and hemorrhagic stroke 

Discuss the relationship between 

hypertension and hemorrhagic stroke 

Review diagnosis of hypertension 

Review prevention, diagnosis, 

management, rehabilitation and outcomes 

of hypertensive hemorrhagic stroke through 

a case study

Intracerebral Hemorrhage 

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Approximately 15% of all strokes are due to 

intracerebral hemorrhage (ICH) 

Incidence 

� 15-19 / 100 000 among the general 

population 

� 200 / 100 000 among the elderly 

More common in men than women

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Primary hemorrhage 

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Spontaneous without obvious underlying cause 

Hypertension and amyloid angiopathy account for 78- 

88% of primary hemorrhages 

Secondary hemorrhage 

� Results from underlying disease 

ICH are typically found in the basal ganglia, 

thalamus, subcortical white matter, cerebellum 

and pons

Most Common Sites and Sources of Intracerebral Hemorrhage 

Qureshi A et al. N Engl J Med 2001;344:1450-1460

Prognosis: ICH Score 

Points 

GCS 3-4 2 

5-12 1 

13-15 0 

ICH volume (cm 3 ) >30 1 

< 

30 0 

IVH Yes 1 

No 0 

Infratentorial Yes 1 

No 0 

Age > 80 years Yes 1 

No 0 

Total Score 30 day 

Mortality 

ICH Volume 

ABC / 2 rule 

0 0% 

1 13% 

2 26% 

3 72% 

4 97% 

5 100%

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ICH is dynamic 

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Hematoma growth occurs in the first few 

hours and is associated with neurological 

deterioration 

Perihematoma edema develops over 3-96 

hours and contributes significantly to 

morbidity and mortality

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Hypertension 

Hypertension is an important risk factor for 

stroke and cardiovascular disease 

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62% of all stroke events are due to suboptimal BP 

¼ of Canadian adults have hypertension 

and it is estimated that 90% will develop 

hypertension over their lifetime 

Hypertension rates are rising at a faster rate 

than predicted

Hypertension and the Vessel 

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High intralumen pressures alter the endothelium 

and smooth muscle in intracerebral arteries 

Degenerative changes in the smooth muscle 

predisposes for ICH 

Endothelial damage can lead to thrombi formation 

and ischemic lesions 

Increased endothelial stress can increase the 

permeability of the blood brain barrier

Hypertension Diagnosis 

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SBP >140 mmHg and/or DBP >90 mmHg 

requires a specific visit for assessment of 

hypertension 

At the initial visit 

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At least three readings should be taken – the first reading 

discarded and the latter two averaged 

History and physical should be performed and diagnostic 

testing to determine end organ damage as indicated 

(CHEP, 2010)

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During the second visit 

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Patients with macrovascular organ damage, 

diabetes or chronic kidney disease can be 

diagnosed with hypertension if SBP remains 

>140 mmHg and/or DBP remains >90 mmHg 

Other patients can be diagnosed with 

hypertension if SBP >180 mmHg and/or DBP 

>110 mmHg 

(CHEP, 2010)

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The remaining patients should have further 

evaluation 

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Office manual BP – the patient can diagnosed as 

hypertensive if SBP >160mmHg or the DBP 

>100mmHg averaged across the three visits OR 

if the SBP averages >140 mmHg or the DBP 

averages >90 mmHg over five vists 

(CHEP, 2010)

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Ambulatory BP monitoring – hypertension can be 

diagnosed if the mean wake SBP >135 mmHg or 

the DBP >85 mmHg OR if the mean 24 hour 

SBP >130 mmHg or the DBP >80mmHg 

Home BP measurement – hypertension can be 

diagnosed if the average SBP >135 mmHg or 

DBP >85 mmHg 

(CHEP, 2010)

Follow up 

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If at the last visit the patient was not diagnosed as 

hypertensive they should be reassessed yearly 

If lifestyle modification alone was recommended 

follow should be at 3 to 6 month intervals 

Patients on antihypertensive drug treatment 

should be seen every 1 to 2 months until readings 

on two consecutive visits are below target then 

should be seen at 3 to 6 months intervals 

(CHEP, 2010)

Lifestyle Modification 

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Exercise 

Weight reduction 

Alcohol consumption 

Dietary recommendations 

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Sodium 

Stress management 

(CHEP, 2010)

Prevention - Hypertension 

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Prevention and treatment of hypertension 

are key 

Hypertensive changes in intracerebral 

vasculature can be modified significantly by 

lifestyle changes such as diet and exercise 

Education surrounding BP monitoring, 

antihypertensive medication adherence and 

lifestyle are essential

Case Study

Mr. W. 

ID 

� 55 year old male, smoker, lives with spouse and 2 

daughters, works as a custodian 

HPI 

� developed severe headache in am 

� became drowsy, confused and developed an unsteady 

gait when walking 

� Presented to ER with ↓ LOA but rousable to speech and 

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continuing to complain of severe headache 

Mr. W.’s spouse reports he had not been taking any of 

his antihypertensive medications for more than a month

Past Medical History 

� Hypertension diagnosed in 2005 

� Hypertensive crisis treated in fall 2008 

� Psoariasis 

Medications 

� Norvasc 15 mg po daily 

� Metoprolol 100 mg po bid 

� Ramipril 10 mg po daily 

� HCTZ 25 mg po daily 

� Terazosin 2 mg po qhs

Physical Exam 

� Neurodrowsy, but arousable, GCS 13/15 oriented 

to person, PEARL, pupils 2mm bilaterally, moving 

all four limbs with 5/5 strength bilaterally 

� BP on admission 236/138 

� Current BP 191/116 

� S1 S2 heart sounds present no audible murmurs 

� Chest sounds clear

Investigations 

� CT head showed ICH with blood in right 

thalamus, extending into ventricular system 

into both lateral ventricles and into third 

ventricle 

� Early changes suspicious for mild 

hydrocephalus 

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Labs 

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Lytes N, creatinine 119, Hgb 158, leukocytes, 

platelets normal

Clinical Management 

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Stroke unit care 

Imaging to determine hemorrhage 

extension, development of hydrocephalus 

Medical management 

Surgical management

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Mr. W was admitted to an intensive care for 

close monitoring of neuro status 

Labetalol infusion was initiated in ER to 

decrease BP (goal SBP < 150 mmHg) 

NPO for potential OR if condition deteriorated 

and evidence of hydrocephalus 

Investigative workup for secondary cause of 

ICH

Course in hospital 

� Blood pressure remained controlled with 

labetalol and oral antihypertensives 

� HCTZ 25mg, metoprolol 150 mg bid, ramipril 

mg, norvasc 10 mg big, terazosin 5mh qHS 

� Neurologically remained stable, no surgical 

intervention 

15

PT initial assessment 

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Cognition/communication 

MSK 

Sensation 

Coordination 

Balance 

Mobility

Assessment findings 

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participation limited 

↓balance 

↓mobility 

↓functional independence 

Plan 

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Follow and progress mobility

OT initial assessment 

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Home environment 

Social support 

BADL 

IADL 

Productivity 

Communication 

Object recognition 

Cognition - MOCA 

Praxis 

Visual Confrontation 

Strength/Coordination/Sensation 

Mobility

OT Recommendations 

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↓cognitive function 

MOCA 22/30 

Deficits in visuospatial/executive, language 

and attention

Social Work 

Issues 

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Regarding payment for medication 

Short term sick leave

Stroke Rehabilitation 

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“Stroke rehabilitation is a progressive, 

dynamic, goal orientated process aimed at 

enabling a person with an impairment to 

reach their optimal physical, cognitive, 

emotional, communicative and/or social 

functional level” 

(Heart and Stroke Foundation of Ontario)

On Admission to Rehabilitation 

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Easily distracted by surroundings 

Severe difficulties with memory 

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Verbal and visual information 

Easily fatigued, both physically and 

cognitively 

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When tired easily irritated, frustrated and angry

Strategies Recommended- Attention 

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Focus on one thing at a time 

Don’t rush 

Work in a quiet environment 

Avoid interruptions 

Socialize in small groups for shorter visits 

Take frequent breaks

Strategies Recommended-Fatigue 

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Maintain regular and structured routine 

Pace yourself 

Alternate physical and mental activities 

throughout the day 

Eat a well balanced diet and exercise 

Take scheduled rest breaks 

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Rest before you are tired

Strategies Recommended-Memory 

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Maintain a predictable routine 

Keep an organized environment 

Keep important items in the same location 

all the time 

Use a dosette to organize medications

Mobility 

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Altered ambulation-required 4 wheeled walker 

� Able to walk short distances with straight 

cane 

Reduced balance. Berg Balance Scale (BBS) 

50/56

Berg Balance Scale (BBS) 

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The BBS measures balance in older adults and 

stroke survivors 

In this 14-item scale, patients must maintain 

positions and complete moving tasks of varying 

difficulty. In most items, patients must maintain 

a given position for a specified time. 

41-56 on the BBS represents good balance. 

(Stroke Engine,2010)

Strategies Implemented: 

Balance & Stability 

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Strengthen and improve motor control in 

proximal muscle groups with activities that 

facilitate hip extension with knee flexion, such 

as bridging exercises 

Improve knee control to avoid or limit 

hyperextension during gait with activities such 

as standing small squats. 

(Ketsner, 2002)

Strategies Implemented-Mobility 

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Treatment concentrated on gait retraining 

and endurance training 

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Walking-progressed to greater distances on 

discharge 

Remembered to use cane in left hand-on 

admission gait better if cane in left handeventually 

no longer required cane

Gait Retraining & Endurance 

Training 

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Practice walking-using cane on various 

surfaces such as carpet, gravel, grass and 

concrete 

Endurance training-using stationary bike, 

focusing on increasing time and resistance

Patient and Family Concerns 

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Participated in adjustment counseling in 

hospital 

It was recommended that Mr. W and family 

continue to participate in counseling after 

discharge to: 

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Reduce stress 

Ease transition home 

Help deal with conflict

Community Reintegration 

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Referral to Regional Community Brain 

Injury Services (RCBIS) 

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Counselors who assist with transition from 

hospital to home 

Services include psychology, life skills and 

independence training and family support 

� Advocacy, social and recreational activities, 

education and information about brain injury

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Multiple visits to emergency room in months 

post discharge: 

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Assessed by clinical psychiatry and social work 

� Cognitive impairment secondary to stroke 

� Demonstrated affective disregulation 

� Severe fatigue 

� Anxiety 

� Periods of lightheadedness 

� 60 pound weight loss

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Most recent ER visit: 

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Hypertensive with BP 170/100 

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Given metoprolol 

to lower BP 

Slurred speech and right leg weakness 

CT head revealed no acute stroke 

Pt revealed that he had not been taking medication 

Referred to stroke prevention clinic for follow-up 

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Has not attended appointment

In Conclusion 

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Prevention and management of 

hypertension is key to modifying stroke risk 

Interprofessional Stroke Care throughout 

the continuum is critical for optimal 

management

Thank you 

Questions

References 

Heart and Stroke Foundation of Ontario. (2010). Retrieved May 15, 

2010 from http://www.heartandstroke.on.ca/site 

/c.pvI3IeNWJwE/b.5339623/k.AD4E/HCP__Hypertension.htm 

Fric-Shamji, E., Shamji, M., Cole, J. & Benoit, B. (2008). Modifiable 

risk factors for intracerebral hemorrhage. Canadian Family 

Physicians, 54: 1138-1139. 

Lai, S., Chen, T., Lee, T., Ro, L. & Hsu, S. (2005). Spontaneous 

intracerebral hemorrhage in young adults. European Journal of 

Neurology, 12: 310-316. 

Leenen, F., Dumais, J., McInnis, N., Turton, P., Stratychuk, L. et al. 

(2008). Results of the Ontario Survey on the prevalence and control 

of hypertension. Canadian Medical Association Journal, 178(11), 

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Mitchell, P., Dipayan, M., Gregson, B. & Mendelow, A. (2007). 

Prevention of intracerebral haemorrhage. Current Drug Targets, 8: 

832-838. 

Passero, S., Ulivelli, M., Reale, F. (2002). Primary intraventricular 

haemorrhage in adults. Acta Neurlogica Scandinavia, 105: 115- 

119. 

Passero, S., Ulivelli, M. & Rossi, S. (2003). Blood pressure rise in 

spontaneous intracerebral haemorrhage: Epiphenomenon or 

precipitating factor . Journal of Human Hypertension, 17: 77-79. 

Rasool, A., Rahman, A., Choudhury, S. & Singh, R. (2004). Blood 

pressure in acute intracerebral haemorrhage. Journal of Human 

Hypertension, 18: 187-192.

Ruhland, J.& van Kan, P. (2003). Medial Pontine Hemorrhagic Stroke. 

Physical Therapy, 83(6), 552-566. 

Sessa, M. (2008). Intracerebral hemorrhage and hypertension. 

Neurological Science, (29): S258-S259. 

Subramaniam, S. & Hill, M. (2006). Intracerebral Hemorrhage. Calgary 

Faculty of Medicine Stroke Rounds, 1(1). Retrieved May 15, 2010 from 

http://strokerounds.ca/crus/strokeng_11_1206.pdf 

Stroke Engine, (2010). Retrieved November 19, 2010 from 

http://www.medicine.mcgill.ca/strokengine-assess/module_bbs_indepthen.html

Thrift, A., McNeil, J., Forbes, A. & Donnan, G. (1998). Three important 

subgroups of hypertensive persons at greater risk of intracerebral 

hemorrhage. American Heart Association, 31: 1223-1229. 

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The Pressure Cooker: Hypertension and Hemorrhagic Stroke

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