Hemorrhagic Stroke Bnf
Cecelia Seiner
Hemorrhagic strokes make up about 13% of stroke cases. They occur when a weakened vessel ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.
Normally, arteries carry blood containing oxygen from the heart to the brain, and veins carry blood with less oxygen away from the brain and back to the heart. When an arteriovenous malformation (AVM) occurs, a tangle of blood vessels in the brain bypasses normal brain tissue and directly diverts blood from the arteries to the veins.
Symptoms may vary depending on where the AVM is located. This could include a wide variety of brain functions, such as difficulties with movement, coordination, sensation, thinking or memory, speech or vision. Severity can vary greatly.
Each time blood leaks into the brain, normal brain tissue is damaged. This results in loss of normal function, which may be temporary or permanent. The chance of permanent brain damage is 20% to 30%. The risk of death related to each bleed is 10% to 15%.
Most AVMs are detected with a computed tomography (CT) brain scan or magnetic resonance imaging (MRI) brain scan. For any type of treatment involving an AVM, an angiogram may be needed to better identify the type of AVM.
The best treatment is usually endovascular surgical blocking of the abnormal connections that have caused the fistula. This involves inserting small tubes (catheters) inside the blood vessel with X-ray guidance and blocking off the abnormal connections.
Surgery: If an AVM has bled and/or is in an area that can be easily accessed, then surgery may be recommended. Microsurgery allows the surgeon to work on small structures in the brain using a microscope and small, precise instruments.
Interventional neuroradiology/endovascular embolization: It may be possible to treat part or all AVM by placing a catheter inside the blood vessels and blocking off the abnormal vessels with various materials such as glue or coils.
Aneurysms usually develop at branching points of arteries and are caused by constant pressure from blood flow. They often enlarge slowly and become weaker as they grow, just as a balloon becomes weaker as it stretches. Aneurysms may be associated with other types of blood vessel disorders, such as fibromuscular dysplasia, cerebral arteritis or arterial dissection, but these are very unusual. Some aneurysms are due to infections, drugs such as amphetamines and cocaine or direct brain trauma from an accident. About 30,000 ruptured cerebral aneurysms occur each year in the U.S. Up to 6% of the population may have an unruptured cerebral aneurysm.
Smaller aneurysms may not have symptoms. As an aneurysm enlarges, it can produce headaches or localized pain. If an aneurysm gets very large, it may produce pressure on the normal brain tissue or adjacent nerves. This pressure can cause difficulty with vision, numbness or weakness of an arm or leg, difficulty with memory or speech, seizures, nausea, vomiting or loss of consciousness.
Many factors determine whether an aneurysm is likely to bleed. These include the size, shape and location of the aneurysm and symptoms that it causes. Smaller aneurysms that are uniform in size may be less likely to bleed than larger, irregularly shaped ones.
*Blood thinners (such as warfarin), some medications and prescription drugs (including diet pills that act as stimulants such as ephedrine and amphetamines), and harmful drugs such as cocaine can cause aneurysms to rupture and bleed.
(*Some medications are commonly called blood thinners because they can help reduce a blood clot from forming. Common blood thinners are anticoagulants such as warfarin or heparin that slow down the clotting process and antiplatelet drugs such as aspirin and clopidogrel that prevent platelet blood cells from clumping together to build a clot.)
After blood enters the brain and the space around it, direct damage to the brain tissue and brain function results. The amount of damage is usually related to the amount of blood. Damage is due to the increased pressure and swelling from bleeding directly into the brain tissue, or from local cellular damage to brain tissue from irritation of blood in the space between the brain and the skull.
Blood can also irritate and damage the normal blood vessels and cause vasospasm (constriction). This can interrupt normal blood flow to the healthy brain tissue and can cause even more brain damage. This is called an ischemic stroke.
Special imaging tests can detect a brain aneurysm. In the CTA (computed tomographic angiography), patients are placed on a table that slides into a CT scanner. A special contrast material (dye) is injected into a vein, and images are taken of the blood vessels to look for abnormalities such as an aneurysm. In the second test, called MRA (magnetic resonance angiography), patients are placed on a table that slides into a magnetic resonance scanner, and the blood vessels are imaged to detect a cerebral aneurysm.
Cerebral angiogram is most reliable in identifying the exact location, size and shape of aneurysms, and can be useful to fully map a plan for therapy. In this test, the patient lies on an X-ray table. A small tube (catheter) is inserted through a blood vessel, usually in the leg (groin), and guided into each of the blood vessels in the neck that go to the brain. Contrast is then injected, and pictures are taken of all the blood vessels in the brain. This test is slightly more invasive and less comfortable.
A stroke that leads to hemorrhage (too much blood in the brain) is called a hemorrhagic stroke. If you have a hemorrhagic stroke caused by a slow accumulation of blood, you may experience symptoms such as headaches, lethargy, and nausea or vomiting.
Your chances of experiencing a hemorrhagic stroke are higher if you are older (over age 65), have a family or personal history of stroke, have uncontrolled diabetes, high cholesterol, or high blood pressure, smoke, are obese, do not exercise, or have a poor diet.
Dr. Heidi Moawad is a neurologist and teaches at Case Western Reserve University School of Medicine in Cleveland, Ohio. She serves on the editorial board of Neurology Clinical Practice and is a reviewer for Neurology.
Adam Felman is an Editor for Medical News Today and Greatist. Outside of work, he is a hearing impaired musician, producer, and rapper who gigs globally. Adam also owns every Nic Cage movie and has a one-eyed hedgehog called Philip K. Prick.
While attempting to establish himself as a recording artist, Robby inadvertently launched himself instead into a career as a technical writer for companies that make musical instruments and recording equipment. Several years ago, he transitioned into writing for a variety of popular digital media companies, where his interest in demystifying complex subject matter for readers found a welcome new outlet. The career shift also allowed Robby to spend more time pursuing his wide-ranging interests, including medical research. He has been writing for Medical News Today since the winter of 2020.
The bleeding in the brain puts pressure on surrounding brain cells and can cause areas of the brain to be deprived of blood. This leads to brain tissue damage, which can lead to neurologic symptoms and be life threatening.
A hemorrhagic stroke is caused by bleeding in the brain. This can happen when a blood vessel in the brain bursts or when brain tissue starts to bleed. The damage from a hemorrhagic stroke can result from pressure caused by bleeding, edema, or a lack of blood supply.
There is an especially high risk of a hemorrhagic stroke after a large ischemic stroke with extensive brain damage and tissue swelling. This is called a hemorrhagic conversion. It can happen anywhere from a few days to 2 weeks after an ischemic stroke.
There are different types of hemorrhagic stroke. An intracerebral hemorrhage is the most common type. In this type, bleeding occurs inside the brain. In a subarachnoid hemorrhage, bleeding occurs between the brain and the membranes that cover it.
According to a 2020 review, Black Americans, Hispanic Americans, and Native Americans all have a higher risk of stroke than white Americans for various socioeconomic and other reasons. The authors recommend improving access to healthcare to help reduce inequity.
Black Americans experience the highest stroke death rate of all racial groups. When it comes to hemorrhagic stroke specifically, Black Americans and Hispanic Americans have a higher risk of recurrence than white Americans.
Immediate treatment for hemorrhagic stroke is essential. Emergency treatment focuses on controlling bleeding and reducing pressure in the brain. This can involve repairing affected blood vessels or sealing an aneurysm.
A surgical procedure known as a craniotomy may be necessary if there is brain swelling. A surgeon will open a small section of the skull to help relieve pressure on the brain that is building up due to the bleeding.
Additionally, a doctor will not recommend the intravenous administration of recombinant tissue plasminogen activator (rtPA), which is a type of medication used to break up blood clots. This medication could worsen bleeding.
A person who has had a stroke may also have a higher risk of having another one. According to the Centers for Disease Control and Prevention (CDC), 1 in 4 strokes that happen each year in the United States affect people who have had a stroke before.
Imaging tests, such as a CT or MRI scan, can show if there is bleeding inside the brain. This can help identify the type of stroke. An electroencephalogram (EEG) gives information about brain function.
Sometimes, an infant experiences a stroke soon after birth, but the symptoms may not be apparent, or they may resemble those of another condition. In some cases, the effects only become apparent as the child develops. The child may show signs of weakness, speech difficulties, and other symptoms, such as headaches.
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