Hemorrhagic Stroke

Hemorrhagic stroke is less common than ischemic stroke. It accounts for about 20% of all strokes. It has a much higher risk of fatality (death) than ischemic strokes. It results from a blood vessel rupturing and hemorrhaging into the brain tissue. The hemorrhage and the resulting edema (swelling) cause the brain to be compressed in the scull. Pressure can be exerted on the brainstem causing coma and death. In hemorrhagic strokes there is also a difference between:

• primary hemorrhage
• hemorrhagic infarct,
• an ischemic stroke in which there has been a secondary hemorrhage

Hemorrhagic stroke has two main types. Each is named according to the part of the brain affected by the bleeding:

• Subarachnoid hemorrhage from bleeding that occurs in the space between the surface of the brain and the skull. A common cause of subarachnoid hemorrhagic stroke is a burst aneurysm (an abnormal “bulging” of a blood vessel in the brain) or the rupture of an ateriovenous malformation, a congenitally malformed tangle of thin-walled blood vessels. For more on subarachnoid hemorrhage
• Intracerebral hemorrhage from bleeding that occurs in the brain tissue. Most intracerebral hemorrhages are caused by a change in the arteries due to long-standing hypertension. Many other potential causes may be defined by additional testing

Causes

• High Blood Pressure (hypertension). High blood pressure causes no symptoms, so people are unaware that they have high blood pressure, and it is not treated. 70% of all strokes (not just hemorrhagic strokes) are related to high blood pressure. Tighter control of blood pressure in diabetics especially reduces the risk of stroke. A blood pressure reading of 120/80 is best for diabetics.
• Aneurysm
• Arteriovenous malformations
• Trauma
• Infections
• Tumours
• Blood clotting problems
• Use of anticoagulants, such as Coumadin or heparin
• Amyloid angiopathy (associated with Alzheimer's disease)

Other Classification of Hemorrhagic Stroke

Petechial Hemorrhages - The passage of a clot through an infarction (blockage) can lead to a localized hemorrhage. In the gray matter of the brain, these are petechial hemorrhages and in the white matter they are pale, ischemic hemorrhages. Infarctions caused by long-standing hypertension are often of the type called “lacunes.” Lacunes are small cystic infarcts and are the most common type of infarction. They result from the occlusion of perforating arteries.

Intracerebral Aneurysms - Aneurysms are weaknesses in the wall of your arteries that may be present at birth. They are usually at points of bifurcation (the splitting off of one vessel from another). Aneurysms are thin-walled sacs which are dilated (enlarged). Aneurysms can become a problem when the dilated (enlarged) sac

• Acts as a space occupying lesion (and presses on part of the brain)
• Ruptures (breaks and bleeds)
• Impairs the circulation of the blood beyond the aneurysm.

Fusiform Dilations and Hemorrhages - Fusiform dilations occur in the Basilar Artery. These dilations are caused by atherosclerosis. The atherosclerosis creates enlarged tortuous (meaning with many twists and turns) vessels which can compress structures next to them creating ischemia or infarctions

Basilar hemorrhages - May be caused by ruptures of the medial or lateral branches of the Basilar Artery. In these cases, there may be bleeding into the area of the Pons. According to Fitzgerald, the symptoms are very severe and will affect both sides of the body because of the swelling (edema) that results. Some of the symptoms that may result are coma, the inability to use all four arms and legs, pin-point pupils, body temperatures rising to 106 degrees over several days, and periodic respiratory arrest

Who gets it?

Intracerebral hemorrhage occurs at all ages, however average age of hemorrhagic stroke is lower than for ischemic stroke.

Treatment

Treatment is based on the underlying cause of the hemorrhage and the extent of damage to the brain. Immediate treatment may include lifesaving measures, surgery to control/repair cause of bleeding or just relief of symptoms

• Medications
  • If high blood pressure is high, antihypertensive drugs are administered to bring blood pressure down.
  • Swelling of brain may be reduced or controlled with hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions).
  • If the hemorrhage resulted from the use of anticoagulants, Coumadin or heparin, medications may be given to reverse the effects of these anticoagulants to reduce bleeding.
  • Pain relievers and antianxiety medications may relieve the headache that often accompanies hemorrhagic stroke.
  • Medications may be needed to prevent or treat seizures.
• Surgery - This information from the Mayo Clinic

Generally there are 3 types of surgeries for hemorrhagic stroke:

• Surgery for Aneurysm
  • Aneurysm Clipping
    Aneurysm clipping involves opening the skull to expose the aneurysm and placing a clip to prevent future leaking of blood from the affected artery. The goal of surgery for subarachnoid bleeding is to reduce the chances of a second bleed from an aneurysm, which is often fatal.
  • Endovascular treatment of aneurysms
    In this procedure, a radiologist passes a catheter (thin tube) through the artery to the opening into an aneurysm. Detachable platinum coils are then deposited in the aneurysm to fill it up and prevent blood from entering, eliminating the possibility of hemorrhage. Other endovascular treatments for aneurysms are being evaluated.
• AVM Treatment

  • Surgical arteriovenous malformation removal
    It is not always possible to remove an arteriovenous malformation (AVM) if it is too large or located deep within the brain. Surgical removal of a smaller AVM from a more accessible portion of the brain can eliminate the risk of AVM rupture. Stereotactic microsurgery, using sophisticated computer technology, cameras and delicate instruments may be used to remove arteriovenous malformations.
  • Stereotactic radiosurgery
    Stereotactic radiosurgery may be used to obliterate AVMs. This procedure focuses a beam of radiation on the AVM, causing it to clot and eventually disappear.
  • Endovascular treatment (coil embolization) of AVMs
    This procedure is similar to the treatment for aneurysms. A catheter is inserted into a leg artery and threaded through the body to the brain arteries. The catheter is positioned in one of the feeding arteries to the AVM, and coils, small particles or a gluelike substance is injected to block the vessel and reduce the blood flow into the AVM. In some large AVMs that appear “inoperable,” embolization makes the AVM smaller, allowing it to be treated with surgery or radiosurgery. In rare cases, endovascular embolization may obliterate or cure the AVM, eliminating the need for other therapy
  • General Hemorrhage Treatments
    • Removal of hematoma
      Removal of a hematoma (a collection of blood, usually clotted, resulting from a break in the wall of a blood vessel) may be needed, especially when bleeding occurs in the back of the brain. Some physicians are investigating whether the injection of a clot busting drug inside the hematoma can help with the removal of brain hemorrhages through needles or catheters, therefore allowing less invasive surgery.
    • Ventriculostomy
      A procedure called ventriculostomy may be performed if fluid accumulates due to bleeding in the brain and needs to be drained

What you can do

• Find out the cause of the stroke (See Tests for more Information) and take the steps required for secondary prevention
• Work with rehabilitation specialists to recover what you can and how to adapt to what you have to.
• Control high blood pressure

When you have a hemorrhage due to hypertension, medical personnel need to be mindful that there can be compression of the Fourth Ventricle and the Brain Stem creating additional problems. Early symptoms include dizziness, vomiting, and ataxia. Ataxia is an unsteady gait as if you were drunk while walking. Later symptoms include coma.

Research information

Hemorrhagic Stroke has received far less attention than ischemic stroke. Hemorrhagic stroke offers potential approach for treatment, some of which are only now being assessed in clinical trials. These include preventing hematoma expansion, reducing any perihemorrhage oligemia, and preventing hemorrhage recurrence. The current status of hemorrhagic stroke

References

Bogousslavsky, J. & Caplan, L. R. (2001). Stroke Syndromes (2nd ed.). Cambridge, Mass.: Cambridge University Press

Caplan, L. R. (2000). Caplan's stroke: A Clinical Approach (3rd ed.). Boston: Butterworth Heinemann

Valenstein, E, Stroke A Synopsis