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Hemorrhagic Stroke

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Iqra Mazhar

A hemorrhagic stroke refers to bleeding within or around the brain. When the blood supply to the brain is cut off, it kills brain cells.

A hemorrhagic stroke results in irreversible brain damage or even death if prompt medical assistance is not received.

Overview

Symptoms of a hemorrhagic stroke differ depending on the part of the brain where the stroke occurs and how much damage is done.

It&rsquo;s imperative to provide emergency care to a patient who&rsquo;s suffered from a hemorrhagic stroke to stop the bleeding and reduce the amount of brain damage.

Intracerebral hemorrhage strokes or ICH is the second most frequent cause of <a href="https://merisehat.pk/disease/stroke">stroke</a>, accounting for 10-15% of all strokes in the U.S.5 
&nbsp;

Hemorrhagic stroke is classified into two categories:

1. Bleeding inside the brain (intracerebral hemorrhage or ICH)

2. Bleeding on the surface of the brain (subarachnoid hemorrhage or SAH)

Different factors, such as faulty blood arteries in the brain, can lead to a hemorrhagic stroke. <a href="https://merisehat.pk/disease/hypertension-57">High blood pressure</a> and a buildup of fatty material in the arteries are two factors that can increase a person&rsquo;s risk of suffering a hemorrhagic stroke. 
&nbsp;

<ul>
	<li>
	<h5>Bleeding Inside The Brain </h5>
	</li>
</ul>

This occurs when blood leaks from a blood vessel into the brain tissue. The majority of hemorrhagic strokes &mdash; roughly two-thirds of all cases &mdash; are ICH, which makes it the most common type of hemorrhagic stroke.6 
&nbsp;

<ul>
	<li>
	<h5>Bleeding On The Surface Of The Brain </h5>
	</li>
</ul>

This occurs when blood leaks from a blood artery on the surface of the brain and enters the protective layer of fluid that surrounds it. The layer is called the subarachnoid space. SAH is the least frequent kind of stroke, accounting for roughly 1 in 3 of all hemorrhagic strokes and about 1 in 20 of all strokes. 
&nbsp;

Signs and Symptoms

Almost all SAH patients who can communicate will talk about having &quot;the worst headache in [their] life&quot; in the hours or days preceding the occurrence. Focal neurologic indications or other symptoms, like nausea or vomiting, unconsciousness, or seizures may also be present at the time of the incident. The symptoms of ICH, on the other hand, are typically described as intensifying over the course of minutes to hours. 
&nbsp;

<h5>To recognize the warning signs of a stroke, think FAST:</h5>

<ul>
	<li>F is for the face. An indication of muscle paralysis or weakness is a droop on one or both sides of the face when the patient tries to smile.</li>
	<li>A is for the arm. Muscle wasting on one side is a common symptom of stroke. If they are weak on one side (and weren&#39;t before), one arm will remain higher while the other sags and drops below when they raise their arms.</li>
	<li>S is for speech. Speaking becomes difficult for many after strokes. Patients have problems finding the correct words or their voice slurs.</li>
	<li>T is for time. Don&#39;t wait to seek help! The sooner the treatment begins, the fewer brain cells will be damaged. 
	&nbsp;</li>
</ul>

A hemorrhagic stroke can cause one or more of the following symptoms:7 
&nbsp;

<ul>
	<li>Headaches, which are sometimes referred to as &quot;thunderclap&quot; headaches by experts due to their abrupt and intense nature</li>
	<li>Light sensitivity; bright lights especially cause severe headaches</li>
	<li>Vertigo or dizziness</li>
	<li>Vomiting and nausea</li>
	<li>Seizures</li>
	<li>Coma</li>
	<li>Dysarthria (slurred or garbled speech) or aphasia (difficulty speaking or loss of speaking ability)</li>
	<li>Difficulty swallowing</li>
	<li>Hand tremors</li>
	<li>Paralysis or weakness on one side</li>
	<li>One-sided loss of all two-sided senses, including hearing, vision, and touch</li>
	<li>Frequent fluctuations in the heartbeat and breathing</li>
	<li>Stiffness in the neck or neck pain 
	&nbsp;</li>
</ul>
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Causes

&nbsp;

<h4>1. Cerebral Small Vessel Disease</h4>

Damage to the brain&#39;s smallest blood vessels is referred to as cerebral small vessel disease. As a result, blood can leak into the brain tissue, often deep inside the brain. There are two major categories of cerebral small vessel disease: 
&nbsp;

<ul>
	<li>
	<h5>Small Vessel Disease Due To High Blood Pressure</h5>
	</li>
</ul>

One of the main causes of small vessel disease in the brain is high blood pressure or hypertension. Over time, high blood pressure affects the blood arteries in the brain, stiffening and blocking them. Small areas of damage develop when the blood flow is reduced. These damaged areas can be picked up by a brain scan. 
&nbsp;

This type of stroke is related to cognitive decline and dementia as it can affect the patient&rsquo;s mood and thinking capacity. It also increases the risk of a hemorrhagic stroke. 
&nbsp;

<ul>
	<li>
	<h5>Cerebral Amyloid Angiopathy (CAA)</h5>
	</li>
</ul>

It&rsquo;s a common type of small vessel disease. The amyloid beta protein accumulates inside the tiny blood vessels close to the surface of the brain, damaging the blood vessels and causing bleeding. This can result in a hemorrhagic stroke as well as microbleeds, which occasionally go undetected. 
&nbsp;

CAA is more common in patients with dementia. Although there isn&#39;t a definitive cure for CAA, managing blood pressure can reduce the chance of brain hemorrhage. 
&nbsp;

<h4>2. Abnormal Blood Vessels In The Brain</h4>

Sometimes, ICH is brought on by rare abnormalities in the brain&#39;s arteries. These are referred to as vascular malformations, which can include blood vessel tangles or enlarged blood vessels. There are two major categories of abnormal blood vessels in the brain: 
&nbsp;

<ul>
	<li>
	<h5>Arteriovenous Malformation (AVM)</h5>
	</li>
</ul>

An AVM occurs when the blood vessels delivering blood to and from the brain tangle up instead of connecting to the entire network of smaller blood vessels in the brain. An AVM constricts blood flow and compresses the nearby brain tissue. Since the blood flows at high pressure that too into relatively weak vessels, it can sometimes cause bleeding. 
&nbsp;

<ul>
	<li>
	<h5>Cavernous Malformation Or Cavernoma</h5>
	</li>
</ul>

A cavernoma is a collection of enlarged blood arteries. It consists of a network of interconnected &quot;bubbles&quot; or caverns. A cavernous malformation is usually asymptomatic, but there&rsquo;s a high possibility that bleeding occurs because the blood vessel walls in this case tend to be weak. 
&nbsp;
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A majority of SAH cases occur due to a burst aneurysm, i.e., a blood vessel balloons out and bursts, resulting in bleeding into the layer of fluid surrounding the brain. A section of a blood vessel enlarges because of chronic and extremely high blood pressure whereas the other cause of an aneurysm &ndash; a weak blood vessel wall &ndash; is congenital. 
&nbsp;

<h5>1. Autosomal Dominant Polycystic Kidney Disease (ADPKD)</h5>

Aneurysms in the brain can be common in people with autosomal dominant polycystic kidney disease (ADPKD). Approximately, 1 in 20 individuals with ADPKD develops aneurysms. 
&nbsp;

<h5>2. Body Tissue Disorders</h5>

Some of the rare disorders, like Marfan syndrome and Ehlers-Danlos syndrome, which affect the connective tissues make the person susceptible to developing a brain aneurysm. Connective tissues are part of the structure of blood vessels and other tissues, like skin and tendons. 
&nbsp;

<h5>3. Coarctation of The Aorta</h5>

A majority of people who are born with aortic stenosis are at risk of developing a brain aneurysm. 
&nbsp;

<h4>Hemorrhagic Stroke in Children</h4>

Strokes in children are less common than in adults. That said, if a child does experience a hemorrhagic stroke, it will present itself as weakness on one side of the body, vomiting, difficulty speaking or seeing, headache, seizure, and reduction or loss of consciousness. 
&nbsp;

It&rsquo;s usually caused by:

<ul>
	<li>Trauma</li>
	<li>Infections</li>
	<li>Some metabolic disorders</li>
	<li>Cancer</li>
	<li>Congenital blood vessel problems</li>
	<li>Blood disorders, like sickle cell disease 
	&nbsp;</li>
</ul>
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Diagnosis

When a doctor suspects a hemorrhagic stroke, they&rsquo;ll order the following tests: 
&nbsp;

<ul>
	<li>A CT or MRI scan is carried out urgently to confirm if there&rsquo;s bleeding in or around the brain </li>
	<li>Blood tests to look for signs of infections or heart damage, checking clotting ability and blood sugar levels, testing how well kidneys and liver function, etc.</li>
	<li>An electrocardiogram is performed to rule out a heart condition as the source of the problem</li>
	<li>A lumbar puncture to check for blood in cerebrospinal fluid as it indicates SAH; however, it&rsquo;s not encouraged because it can be dangerous and make it worse9</li>
	<li>A catheter angiogram or digital subtraction angiogram that uses X-rays to locate the burst blood vessel</li>
	<li>A neurological or eye exam to check the swelling of the optic nerve 
	&nbsp;</li>
</ul>
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Treatment

Immediate medical attention helps prevent life-threatening complications. However, a doctor has to make sure of the cause, size, and location of a hemorrhagic stroke to devise a holistic treatment plan. 
&nbsp;

If the rupture is small and/or causes only a small amount of bleeding, emergency care, including IV fluids, management of medical problems, rest and therapy (speech, physical, and occupational), and surgery (for severe cases) can help treat and manage the impact of the stroke.

<h4>Medication6</h4>

<ul>
	<li>An SAH leads to vasospasm, i.e., the brain&rsquo;s blood arteries narrow and the amount of blood flow in the brain reduces. Vasospasm occurs between days 1-3 weeks following a stroke. It makes the condition more serious, which is why doctors may prescribe nimodipine for 3 weeks to prevent it6.</li>
	<li>Also, medication to counteract the effects of warfarin may also be prescribed for patients who&rsquo;re using the blood-thinning or other anti-clotting drugs. 
	&nbsp;</li>
</ul>

Other medications that are prescribed include painkillers to deal with the SAH-associated severe headache as well as medication to control high blood pressure and high or low sugar levels.

<ul>
	<li>A doctor will NOT recommend intravenous administration of recombinant tissue plasminogen activator as it can worsen bleeding .8</li>
</ul>

<h4>Surgical Procedure</h4>

Surgery is required for more serious strokes to either relieve the pressure caused by swelling or bleeding or to repair the ruptured blood vessel to stop it from bleeding. 
&nbsp;

<h5>1. Craniotomy</h5>

Sometimes, the pressure inside the skull can increase as a result of bleeding or brain swelling. This procedure removes a portion of the skull to relieve pressure on the brain and allow the surgeon to repair damaged blood vessels. 
&nbsp;

<h5>2. Shunt Surgery </h5>

A SAH occasionally causes hydrocephalus, a dangerous accumulation of fluid surrounding the brain. It occurs when the cerebrospinal fluid that usually surrounds the brain and spinal cord does not flow properly, causing symptoms like headache and vomiting.

A shunt is implanted in the brain to drain fluid to another area of the body. 
&nbsp;

<ul>
	<li>
	<h5>Coiling</h5>
	</li>
</ul>

To treat aneurysms near the brain, a catheter is placed into an artery in the groin and carefully guided up to the aneurysm by X-rays. The aneurysm is sealed by having tiny platinum coils inserted through the tube. 
&nbsp;

<ul>
	<li>
	<h5>Clipping</h5>
	</li>
</ul>

Clipping involves removing a small piece of bone from the skill and using a tiny titanium clip to close the aneurysm. The scalp is stitched back once the clip has been secured and the bone fragment restored. 
&nbsp;

<h5>3. Seizures Treatment</h5>

A hemorrhagic stroke might cause some people to experience seizures. A seizure doesn&rsquo;t necessarily mean that the individual will have epilepsy, too. A doctor will assess the patient&rsquo;s age and risk of developing epilepsy to determine the best course of treatment for them. 
&nbsp;

<h5>4.&nbsp;Headaches After Hemorrhagic Stroke</h5>

A person can experience headaches while they recover from a hemorrhagic stroke. Some patients reportedly also experience odd sensations in their brains, like tickling or the sound of rushing water, after a SAH. While these sensations typically go away with time, it&rsquo;s imperative to seek immediate medical assistance if the headache is severe, persistent, or occurs very suddenly.&nbsp; 
&nbsp;

NOTE: Do NOT use a painkiller for headaches without consulting a doctor or a pharmacist. 
&nbsp;

<h5>5. Rehabilitation</h5>

A rehab program is intended to help patients recover their bodily functions, regain strength and live independently as much as possible, depending of course on the area of the brain affected and the degree of damage incurred.

&nbsp;

The focus is on:

<ul>
	<li>A healthy diet</li>
	<li>A regular exercise schedule</li>
	<li>A no-smoking policy</li>
	<li>A proper sleep schedule</li>
	<li>Speech, occupational, and physical therapy sessions</li>
	<li>Management of body weight</li>
	<li>Ensuring that the patient follows the treatment plan and attends follow-up appointments</li>
	<li>Monitoring new or worsening symptoms or complications</li>
	<li>Seeking support from healthcare professionals and loved ones</li>
</ul>

<h5> 
6. Life Support</h5>

Life support procedures include CPR, dialysis, ventilation, tube feeding, etc. The purpose is to support or replace a failing organ to keep the individual alive until their body starts functioning normally again. The decision to use life support is personal; a doctor may suggest it, but won&rsquo;t start it if the person or their loved ones decline it. 
&nbsp;
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A stroke can cause temporary or permanent disabilities, depending on which part of the brain&rsquo;s affected and how long it lacks blood flow. Complications of hemorrhagic stroke include: 
&nbsp;

<ul>
	<li>Stroke</li>
	<li>Mental health issues, like depression</li>
	<li>Blood clots, which can cause deep vein thrombosis or pulmonary embolism</li>
	<li>Seizures</li>
	<li>Brain swelling</li>
	<li>Memory loss, or difficulty reasoning, thinking, and understanding concepts</li>
	<li>Muscle weakness</li>
	<li>Vision and hearing problems</li>
	<li>Decreased sensation</li>
	<li>Bed sores</li>
	<li>Paralysis or loss of muscle movement</li>
	<li>Shoulder pain</li>
	<li>Difficulty swallowing or talking</li>
	<li>Emotional disability</li>
	<li>Loss of vision</li>
	<li>Loss of bowel or bladder control</li>
	<li>Pressure sores</li>
	<li>Urinary tract infections</li>
	<li>Changes in behavior, i.e., more withdrawn</li>
	<li>Changes in self-care ability, i.e., more dependent on others for grooming and completion of other daily chores</li>
	<li>Death is possible; it may occur despite prompt medical treatment 
	&nbsp;</li>
</ul>
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Some factors that can increase a person&rsquo;s chance of having a hemorrhagic stroke include: 
&nbsp;

<h5>Age </h5>

<ul>
	<li>ICH can happen to anyone, but it&rsquo;s more common in people over 70.</li>
	<li>Anyone can get a SAH, but persons between the ages of 45 and 70 are more likely to experience one. 
	&nbsp;</li>
</ul>

<h5>High Blood Pressure</h5>

The brain&#39;s blood vessels become damaged and are more likely to hemorrhage as a result of high blood pressure. A blood pressure medication can lower the risk of having another stroke. 
&nbsp;

High blood pressure can also be kept in check by quitting smoking, increasing the activity level, and, if necessary, reducing weight. 
&nbsp;

<h5>Blood-Thinning Medication</h5>

Blood thinners help lower your risk of stroke and blood clots. It&#39;s frequently administered to patients who have had an ischemic stroke (caused by a blockage or clot) and those at risk of stroke because of a heart problem, like atrial fibrillation.

However, this medication increases the risk of bleeding in the brain. 
&nbsp;

NOTE: Do NOT stop the medicine without consultation with a doctor. Stopping it suddenly or without a doctor&rsquo;s advice is risky. When a patient suffers from a hemorrhagic stroke while taking this medication, their doctor will carefully evaluate if they should stop taking it or switch to a different type. 
&nbsp;

<h5>Alcohol Consumption</h5>

Alcohol consumption can increase the risk of developing high blood pressure and stroke. 
&nbsp;

<h5>Illegal Drugs</h5>

The risk of a hemorrhagic stroke increases with frequent usage of illegal substances, like cocaine, amphetamines, and cannabis. 
&nbsp;

<h5>Other</h5>

<ul>
	<li>A physical trauma or a head injury</li>
	<li>A bleeding disorder</li>
	<li>High levels of LDL cholesterol</li>
	<li>Diabetes</li>
	<li>Smoking, including vaping and smokeless tobacco</li>
	<li>High levels of stress and anxiety</li>
	<li>Family history of stroke</li>
	<li>A history of cardiovascular disease</li>
	<li>Sedentary lifestyle</li>
	<li>Excess weight around the waist</li>
	<li>Side effects of radiation treatment 
	&nbsp;</li>
</ul>
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The most important thing is to keep the blood pressure at a healthy range. 
&nbsp;

Lifestyle changes such as the following can help prevent a hemorrhagic stroke: 
&nbsp;

<ul>
	<li>Manage health conditions, including blood pressure, Type 2 diabetes, and cholesterol.</li>
	<li>Eating a healthy diet and keeping the weight under control can help prevent or delay a stroke because they have a big impact on the heart and vascular health.</li>
	<li>Schedule an annual appointment with a physician to detect any symptoms early.</li>
	<li>Avoid/Quit risky behaviors, such as drinking alcohol, misusing prescription medications, or smoking and using tobacco products (e.g., vaping). 
	&nbsp;</li>
</ul>
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<h5>Hemorrhagic Stroke and Anticoagulation in COVID-19</h5>

Numerous anticoagulant treatments are currently under consideration for this purpose ever since it&rsquo;s been revealed that COVID-19 patients are at greater risk of thrombotic events and death. 
&nbsp;

Anticoagulation increases the risk of adverse bleeding incidents, like ICH. This study is a retrospective analysis of 33 patients, with neuroimaging-confirmed ICH and positive COVID-19 results, who were given anticoagulation therapy. All of these patients were over the age of 18. 
&nbsp;

The study offered crucial preliminary information on ICH and anticoagulation in hospitalized COVID-19 patients. There were 33 COVID-19 patients with ICH, 21.2% of whom were female. Parenchymal hemorrhages with herniation and mass effect were observed in 5 patients, with a 100% mortality rate, whereas 4 patients had a large single site of hemorrhage, 7 patients had punctate hemorrhages, and 17 had small-moderate size hemorrhages. Almost all of them had received either a prophylactic dose or therapeutic dose anticoagulation before ICH.&nbsp; 
&nbsp;

It was concluded that anticoagulation therapy can be given to COVID-19 patients. However, doctors should consider the risk of ICH before they make it part of a treatment regimen. 
&nbsp;
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Key Points

<ul>
	<li>A hemorrhagic stroke occurs when a blood artery supplying the brain bursts and bleeds. Consequently, the brain&#39;s cells and tissues do not receive enough oxygen and nutrients.</li>
	<li>A stroke leads to pressure buildup, which causes discomfort and edema.</li>
	<li>Millions of brain cells are destroyed every second. The more quickly the patient is given medical care, the fewer cells will be harmed, and the more quickly the patient can recover. 
	&nbsp;</li>
</ul>
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[1] Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(6):2001–23.

[2] Walker MT, Nemeth A. Emergency Neuroradiology, An Issue of Radiologic Clinics of North America. Vol. 49. Elsevier Health Sciences; 2011.

[3] Adams Jr HP, Adams RJ, Brott T, Del Zoppo GJ, Furlan A, Goldstein LB, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. stroke. 2003;34(4):1056–83.

[4] Dogra S, Jain R, Cao M, Bilaloglu S, Zagzag D, Hochman S, et al. Hemorrhagic stroke and anticoagulation in COVID-19. J Stroke Cerebrovasc Dis. 2020;29(8):104984.