Classification of Hemorrhagic Strokes

7/29/2019 Classification of Hemorrhagic Strokes

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Classification of Hemorrhagic Strokes

Hemorrhagic strokes include bleeding within the brain (intracerebral hemorrhage)

and bleeding between the inner and outer layers of the tissue covering the brain

(subarachnoid hemorrhage).

There are two main types of hemorrhagic strokes: intracerebral hemorrhage and

subarachnoid hemorrhage. Other disorders that involve bleeding inside the skull

include epidural hematomas (seeHead Injuries: Epidural Hematomas) and subdural

hematomas (see seeHead Injuries: Subdural Hematomas), which are usually caused

by a head injury. These disorders cause different symptoms and are not considered

strokes.

Bursts and Breaks: Causes of Hemorrhagic Stroke

When blood vessels of the brain are weak, abnormal, or under unusual pressure,

a hemorrhagic stroke can occur. In hemorrhagic strokes, bleeding may occur

within the brain, as an intracerebral hemorrhage. Or bleeding may occur between

the inner and middle layer of tissue covering the brain (in the subarachnoidspace), as a subarachnoid hemorrhage.

Intracerebral Hemorrhage

An intracerebral hemorrhage is bleeding within the brain.

Intracerebral hemorrhage usually results from chronic high blood pressure. The first symptom is often a severe headache. Diagnosis is based on symptoms and results of a physical examination and

imaging tests.

Treatment may include vitamin K, transfusions, and, rarely, surgery to
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remove the accumulated blood.

Intracerebral hemorrhage accounts for about 10% of all strokes but for a much

higher percentage of deaths due to stroke. Among people older than 60, intracerebral

hemorrhage is more common than subarachnoid hemorrhage.

Causes

Intracerebral hemorrhage most often results when chronic high blood pressure

weakens a small artery, causing it to burst. Using cocaine or amphetamines can

cause temporary but very high blood pressure and hemorrhage. In some older

people, an abnormal protein called amyloid accumulates in arteries of the brain. This

accumulation (called amyloid angiopathy) weakens the arteries and can cause

hemorrhage.

Less common causes include blood vessel abnormalities present at birth, injuries,

tumors, inflammation of blood vessels (vasculitis), bleeding disorders, and use ofanticoagulants in doses that are too high. Bleeding disorders and use of

anticoagulants increase the risk of dying from an intracerebral hemorrhage.

Symptoms

An intracerebral hemorrhage begins abruptly. In about half of the people, it begins

with a severe headache, often during activity. However, in older people, the

headache may be mild or absent. Symptoms suggesting brain dysfunction develop

and steadily worsen as the hemorrhage expands. Some symptoms, such as weakness,

paralysis, loss of sensation, and numbness, often affect only one side of the body.

People may be unable to speak or become confused. Vision may be impaired or lost.

The eyes may point in different directions or become paralyzed. The pupils may

become abnormally large or small. Nausea, vomiting, seizures, and loss of

consciousness are common and may occur within seconds to minutes.

Diagnosis

Doctors can often diagnose intracerebral hemorrhages on the basis of symptoms and

results of a physical examination. However, computed tomography (CT) or

magnetic resonance imaging (MRI) is also done. Both tests can help doctors

distinguish a hemorrhagic stroke from an ischemic stroke. The tests can also showhow much brain tissue has been damaged and whether pressure is increased in other

areas of the brain. The blood sugar level is measured because a low blood sugar

level can cause symptoms similar to those of stroke.

Prognosis

Intracerebral hemorrhage is more likely to be fatal than ischemic stroke. The

hemorrhage is usually large and catastrophic, especially in people who have chronic

high blood pressure. More than half of the people who have a large hemorrhage die

within a few days. Those who survive usually recover consciousness and some brain

function over time. However, most do not recover all lost brain function.


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Treatment

Treatment of intracerebral hemorrhage differs from that of an ischemic stroke.

Anticoagulants (such as heparin and warfarin

), thrombolytic drugs, and antiplatelet drugs (such as aspirin

) are not given because they make bleeding worse. If people who are taking an

anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood

clot such as

Vitamin K, usually given intravenously Transfusions of platelets Transfusions of blood that has had blood cells and platelets removed (fresh

frozen plasma)

Intravenous administration of a synthetic product similar to the proteins inblood that help blood to clot (clotting factors)

Surgery to remove the accumulated blood and relieve pressure within the skull, even

if it may be life-saving, is rarely done because the operation itself can damage the

brain. Also, removing the accumulated blood can trigger more bleeding, further

damaging the brain and leading to severe disability. However, this operation may be

effective for hemorrhage in the pituitary gland or in the cerebellum. In such cases, a

good recovery is possible.

Subarachnoid Hemorrhage

A subarachnoid hemorrhage is bleeding into the space (subarachnoid space)

between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue

covering the brain (meninges).

The most common cause is rupture of a bulge (aneurysm) in an artery. Usually, rupture of an artery causes a sudden, severe headache, often

followed by a brief loss of consciousness.

Computed tomography, sometimes a spinal tap, and angiography are done toconfirm the diagnosis.

Drugs are used to relieve the headache and to control blood pressure, andsurgery is done to stop the bleeding.

A subarachnoid hemorrhage is a life-threatening disorder that can rapidly result in

serious, permanent disabilities. It is the only type of stroke more common among

women than among men.

Causes

Subarachnoid hemorrhage usually results from head injuries. However, hemorrhage

due to a head injury causes different symptoms and is not considered a stroke.

Subarachnoid hemorrhage is considered a stroke only when it occursspontaneouslythat is, when the hemorrhage does not result from external forces,


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such as an accident or a fall. A spontaneous hemorrhage usually results from the

sudden rupture of an aneurysm in a cerebral artery. Aneurysms are bulges in a

weakened area of an artery's wall. Aneurysms typically occur where an artery

branches. Aneurysms may be present at birth (congenital), or they may develop

later, after years of high blood pressure weaken the walls of arteries. Most

subarachnoid hemorrhages result from congenital aneurysms.

Less commonly, subarachnoid hemorrhage results from rupture of an abnormal

connection between arteries and veins (arteriovenous malformation) in or around the

brain. An arteriovenous malformation may be present at birth, but it is usually

identified only if symptoms develop. Rarely, a blood clot forms on an infected heart

valve, travels (becoming an embolus) to an artery that supplies the brain, and causes

the artery to become inflamed. The artery may then weaken and rupture.

Did You Know...

Almost half of people with asubarachnoid hemorrhage die

before reaching the hospital.

Symptoms

Before rupturing, an aneurysm usually causes no symptoms unless it presses on a

nerve or leaks small amounts of blood, usually before a large rupture (which causes

headache). Then it produces warning signs, such as the following:

Headache, which may be unusually sudden and severe (sometimes called athunderclap headache) Facial or eye pain Double vision Loss of peripheral vision

The warning signs can occur minutes to weeks before the rupture. People should

report any unusual headaches to a doctor immediately.

A rupture usually causes a sudden, severe headache that peaks within seconds. It is

often followed by a brief loss of consciousness. Almost half of affected people die

before reaching a hospital. Some people remain in a coma or unconscious. Otherswake up, feeling confused and sleepy. They may also feel restless. Within hours or

even minutes, people may again become sleepy and confused. They may become

unresponsive and difficult to arouse. Within 24 hours, blood and cerebrospinal fluid

around the brain irritate the layers of tissue covering the brain (meninges), causing a

stiff neck as well as continuing headaches, often with vomiting, dizziness, and low

back pain. Frequent fluctuations in the heart rate and in the breathing rate often

occur, sometimes accompanied by seizures.

About 25% of people have symptoms that indicate damage to a specific part of the

brain, such as the following:

Weakness or paralysis on one side of the body (most common)


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Loss of sensation on one side of the body Difficulty understanding and using language (aphasiaseeBrain

Dysfunction: Aphasia)

Severe impairments may develop and become permanent within minutes or hours.

Fever is common during the first 5 to 10 days.

A subarachnoid hemorrhage can lead to several other serious problems:

Hydrocephalus: Within 24 hours, the blood from a subarachnoidhemorrhage may clot. The clotted blood may prevent the fluid surrounding

the brain (cerebrospinal fluid) from draining as it normally does. As a result,

blood accumulates within the brain, increasing pressure within the skull.

Hydrocephalus may contribute to symptoms such as headaches, sleepiness,

confusion, nausea, and vomiting and may increase the risk of coma and

death.

Vasospasm: About 3 to 10 days after the hemorrhage, arteries in the brainmay contract (spasm), limiting blood flow to the brain. Then, brain tissues

may not get enough oxygen and may die, as in ischemic stroke. Vasospasm

may cause symptoms similar to those of ischemic stroke, such as weakness

or loss of sensation on one side of the body, difficulty using or

understanding language, vertigo, and impaired coordination.

A second rupture: Sometimes a second rupture occurs, usually within aweek.

Diagnosis

If people have a sudden, severe headache that peaks within seconds or that is

accompanied by any symptoms suggesting a stroke, they should go immediately to

the hospital. Computed tomography (CT) is done to check for bleeding. A spinal tap

(lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any

blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that

pressure within the skull is increased. Cerebral angiography (seeBrain Dysfunction:

Aphasia) is done as soon as possible to confirm the diagnosis and to identify the site

of the aneurysm or arteriovenous malformation causing the bleeding. Magnetic

resonance angiography or CT angiography may be used instead.

Prognosis

About 35% of people die when they have a subarachnoid hemorrhage due to an

aneurysm because it results in extensive brain damage. Another 15% die within a

few weeks because of bleeding from a second rupture. People who survive for 6

months but who do not have surgery for the aneurysm 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 because the defect has already sealed itself off. In

such cases, the outlook is very good.

Some people recover most or all mental and physical function after a subarachnoidhemorrhage. However, many people continue to have symptoms such as weakness,
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paralysis, or loss of sensation on one side of the body or aphasia.

Treatment

People who may have had a subarachnoid hemorrhage are hospitalized immediately.

Bed rest with no exertion is essential. Analgesics such as opioids (but not aspirin

or other nonsteroidal anti-inflammatory drugs, which can worsen the bleeding) are

given to control the severe headaches. Stool softeners are given to prevent straining

during bowel movements. Nimodipine, a calcium channel blocker, is usually given

by mouth to prevent vasospasm and subsequent ischemic stroke. Doctors take

measures (such as giving drugs and adjusting the amount of intravenous fluid given)

to keep blood pressure at levels low enough to avoid further hemorrhage and high

enough to maintain blood flow to the damaged parts of the brain. Occasionally, a

piece of plastic tubing (shunt) may be placed in the brain to drain cerebrospinal fluid

away from the brain. This procedure relieves pressure and prevents hydrocephalus.

For people who have an aneurysm, a surgical procedure is done to isolate, block off,

or support the walls of the weak artery and thus 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 who are in a stupor or coma. The best time for

surgery is controversial and must be decided based on the person's situation. Most

neurosurgeons recommend operating within 24 hours of the start of symptoms,

before hydrocephalus and vasospasm develop. If surgery cannot be done this

quickly, the procedure may be delayed 10 days to reduce the risks of surgery, but

then bleeding is more likely to recur because the waiting period is longer.

A commonly used procedure, called neuroendovascular surgery, involves inserting

coiled wires into the aneurysm. The coils are placed using a catheter that is inserted

into an artery and threaded to the aneurysm. Thus, this procedure does not require

that the skull be opened. By slowing blood flow through the aneurysm, the coils

promote clot formation, which seals off the aneurysm and prevents it from

rupturing. Neuroendovascular surgery can often be done at the same time as cerebral

angiography, when the aneurysm is diagnosed.

Less commonly, a metal clip is placed across the aneurysm. This procedure prevents

blood from entering the aneurysm and eliminates the risk of rupture. The clip

remains in place permanently. Most clips that were placed 15 to 20 years ago areaffected by the magnetic forces and can be displaced during magnetic resonance

imaging (MRI). People who have these clips should inform their doctor if MRI is

being considered. Newer clips are not affected by the magnetic forces.

Hemorrhagic Stroke Risk Factors

High Blood PressureHigh blood pressure is the most common cause of ICH, responsible for about 60 percent of

all cases. It is the most important controllable stroke risk factor. Have your blood pressure

checked regularly. If it is consistently more than 140/90 speak with your healthcare provider

about treatment options.


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Alcohol and Drug AbuseExcessive alcohol and drug use have been associated with higher incidences of ICH and

SAH. About 85 to 90 percent of drug-associated ICH cases occur in people in their 20s or

30s. If you drink alcohol, do so only in moderation. If you don't drink, don't start.

Blood Anti-Clotting MedicationAlthough anti-clotting medication may prevent ischemic stroke, if your blood becomes "too

thin", you may be at risk for an ICH. Check with your doctor for guidance about anti-clotting

medication.

Blood Clotting DisordersIf you have any type of blood disorder, such as hemophilia or sickle cell anemia, be sure to

speak with your healthcare provider. There are ways you can control it to decrease your

stroke risk.

Causes

Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very

sensitive to bleeding and damage can occur very rapidly. Bleeding irritates the brain tissue,

causing swelling. Bleeding collects into a mass called a hematoma. Bleeding also increases

pressure on the brain and presses it against the skull.

Hemorrhagic strokes are grouped according to location of the blood vessel:

Intracerebral hemorrhage: Bleeding in the brain Subarachnoid hemorrhage: Bleeding in the area between the brain and the thin tissues that

cover the brain

Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls

until they break.

Other causes of hemorrhagic stroke include:

Aneurysms, which create a weak spot in an artery wall, which can eventually burst Abnormal connections between arteries and veins, such as anarteriovenous malformation

(AVM) Cancer, particularly cancer that spreads to the brain from distant organs such as the breast,

skin, and thyroid

Cerebral amyloid angiopathy, a build up of amyloid protein within the artery walls in thebrain, which makes bleeding more likely

Conditions or medications (such as aspirin or Warfarin) that can make you bleed excessively Illicit drugs, such as cocaine
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Classification of Hemorrhagic Strokes