Hemorrhage Stroke

A hemorrhagic stroke is damage to brain tissue resulting from bleeding inside the skull.

• There are two main types of hemorrhagic strokes: intracerebral hemorrhage and subarachnoid hemorrhage.
• Intracerebral hemorrhage occur within the brain while subarachnoid hemorrhage occur within a space between pia and arachnoid mater of the tissue covering the brain (meninges).
• Bleeding inside the skull can also result in epidural and subdural hematomas, which are usually caused by a head injury and cause different symptoms.

Intracerebral Hemorrhage

An intracerebral hemorrhage is bleeding within the brain.

• Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher percentage of death due to stroke.
• Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage.
• Causes of intracerebral hemorrhage include high blood pressure and in older people, fragile blood vessels.
• Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.

Symptoms and Diagnosis

• An intracerebral hemorrhage begin abruptly. In about half of the people, it begins with a severe headache.
• Neurologic symptoms develop and steadily worsen. They include weakness, paralysis, numbness, loss of speech or vision, and confusion.
• Symptoms worsen as the hemorrhage expands. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes.
• Doctor can often diagnose intracerebral hemorrhages on the basic of symptoms and the results of a physical examination.
• However, CT or MRI scan is usually performed when a stroke is suspected. Both procedures can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The procedures can also detect how much brain tissue has been damaged and whether pressure is increased in other areas of the brain.
• A lumbar puncture (LP) is not usually performed. LP cab cause herniation of the brain, a life threatening disorder.

Treatment and Prognosis.

• Treatment of hemorrhagic stroke differs from that of an ischemic stroke.
• Anticoagulants, thrombolytic drugs, and anti-platelet drugs (such as aspirin) are not given, and surgery may save the person's life.
• The goal of surgery is to remove blood that has accumulated in the brain and to relieve the resulting increased pressure.
• Stroke due to intracerebral hemorrhage is more dangerous that ischemic stroke. The stroke is usually large and catastrophic, especially in people who have chronic high blood pressure.
• More than have of the people who have large hemorrhages die within a few days. Those who survive usually recover consciousness and some bran function as the body absorbs the leaked blood.
• Ever after surgery, many people continue to have some neurologic symptoms. The symptoms may include weakness, paralysis, loss of sensation on one side of the body, or difficulty understanding and using language (aphasia).
• However, people with small hemorrhages recover to a remarkable degree.

Subarachnoid Hemorrhage

A subarachnoid hemorrhage is sudden bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the meninges.

• Usually, the cause is the sudden rupture of an aneurysm in a cerebral artery or blood vessel (atriovenous) malformation of the arteries or veins in or around the brain.
• An aneurysm may rupture because of the pressure of blood inside the artery; hemorrhage and stroke may result.
• An arteriovenous malformation may be present at birth, but it is identified only if symptoms develop, it may cause bleeding, usually during adolescence or young adulthood, and sudden collapse, stroke, and death may result.
• Rarely, atherosclerosis or a bacterial infection damage a blood vessel, causing it to rupture. Ruptures can occur in people of any age of 25 and 50. A subarachnoid hemorrhage can also result from a head injury.
• A subarachnoid hemorrhage is the only one type of stroke more common among women than among men.

Symptoms and Diagnosis

• Before rupturing, aneurysms that cause subarachnoid hemorrhages usually produce no symptoms. However, aneurysm sometimes press on a nerve or leak small amounts of blood before a major rupture, thereby producing warning signs, such as headache, facial pain, double vision, or other visual problems.
• The warning signs can occur minutes to weeks before the rupture. People should always report such symptoms to a doctor immediately, because steps may be taken to prevent a massive hemorrhage.
• A rupture usually produces a sudden, severe headache, often followed by a brief loss of consciousness. Some people remain in a coma, but more people wake up, feeling confused and sleepy.
• Blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), producing dizziness.
• Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures. Within hours or even minutes, people may again become sleepy and confused.
• About 25% of people have neurologic symptoms, usually paralysis on one side of the body.
• A subarachnoid hemorrhage can usually be diagnosed by CT scan, which pinpoints the site of bleeding.
• LP if necessary can detect any blood in the CSF.
• Cerebral angiography is usually performed within 72 hours to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding, so that surgery can be performed.

Treatment and Prognosis

• People who may have had a subarachnoid hemorrhage are hospitalized immediately and instructed to avoid exertion.
• Analgesics such as opioids (but not aspirin or other NSAID) are given to control the severe headaches.
• Occasionally, a drainage tube may be placed in the brain to relieve pressure.
• Nimodipine, a calcium channel blocker, is usually given to prevent spasm of an artery. This drug helps prevent late spasm and ischemic stroke.
• For people who have an aneurysm, surgery that isolates, blocks off, or supports the walls of the weak artery reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people whoa are in a stupor or coma.
• The best time for surgery is somewhat controversial and must be decided based on the person's situation.
• Most neurosurgeon recommend operating within 3 days of the start of symptoms, before the brain becomes swollen and inflamed.
• Delaying in operation 10 or more days reduces the risk of surgery, but bleeding is more likely to recur in the longer interim.
• A common procedure is placement of a metal clip across the aneurysm, which prevents blood from entering the aneurysm and thus eliminates the risk of rupture. People who have clips remains on place permanently.
• People who had clips placed years ago cannot undergo MRI: newer clips are not affected by the magnetic forces.
• An alternative procedure, called neuroendovascular surgery, involves the insertion of coiled wires into the aneurysm. The coils are placed using a catheter inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened. By slowing blood flow, the coils promote clot formation, which seals of the aneurysm.
• About 35% if people who have a subarachnoid hemorrhage due to an aneurysm die during the first episode because of extensive brain damage.
• Another 15% die within a few weeks because of subsequent bleeding.
• People who survive for 6 months but who do not have surgery for the aneurysm may have a 3% chance of another rupture each year.
• The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography becayse it has already sealed itself off. In such cases, the outlook is very good.
• Many people recover most or all mental and physical function after a subarachnoid hemorrhage.
• However, neurologic symptoms, such as weakness, paralysis, loss of sensation on one side of the body, or difficulty in understanding and using language (aphases) sometimes persist.