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Hemorrhagic Stroke

Alternate Names

  • stroke
  • brain attack
  • CVA
  • cerebrovascular accident
  • Brain hemorrhage
  • Deep intracerebral hemorrhage

Definition

A stroke is the death of brain tissue that occurs when the brain does not get enough blood and oxygen. Hemorrhagic stroke is a serious condition that occurs when blood seeps into the brain tissue from a damaged blood vessel.

What is going on in the body?

A hemorrhagic stroke occurs when blood vessels in the brain burst and release blood into the the brain. This prevents normal blood flow to brain cells in the area of the hemorrhage, causing cell death. In addition, the blood can damage nearby brain cells by pushing them out of their normal place.
The products released when cells die cause swelling in the brain. Since the skull has little room for expansion, this swelling can lead to increased pressure within the skull and damage the brain tissue even further, leading to coma or death.

Risks

What are the causes and risks of the condition?

A hemorrhagic stroke may be associated with:
  • high blood pressure
  • heart disease
  • high cholesterol
  • diabetes
  • previous history of stroke
  • diabetes mellitus
  • abnormal bleeding from blood-thinning medications, such as warfarin or heparin
  • hemophilia A or hemophilia B, which are blood disorders that prevent normal blood clotting
  • low numbers of platelets, a type of blood cell involved in blood clotting. Low platelet counts are seen in a number of diseases and conditions, including acute infections and a severe allergic reaction known as anaphylactic shock.
  • rupture of a cerebral aneurysm, or weakened blood vessel wall within the brain
  • sickle cell disease, an inherited condition that results in abnormal red blood cells
  • a group of abnormal blood vessels within the brain known as an arteriovenous malformation or AVM
  • head injuries
  • eclampsia, a complication of pregnancy that causes high blood pressure in the mother
  • cocaine use
  • phenylpropanolamine, a compound contained in appetite suppressants and cold remedies, significantly increased the risk of hemorrhagic stroke in women 18 to 49 years of age. The Food and Drug Administration (FDA) has since required manufacturers to remove phenylpropanolamine from their product lines.

Prevention

What can be done to prevent the condition?

Some hemorrhagic strokes can be prevented through careful control of the underlying disease or disorder. For individuals with diagnosed cerebral aneurysms, guidelines for monitoring and treatment should be followed. Hemorrhagic stroke from head injuries can be minimized by following sports safety guidelines for children, adolescents, and adults.
The American Heart Association (AHA) guidelines for stroke prevention address both modifiable and less well-documented or potentially modifiable risk factors.
Measures to reduce the modifiable risk of high blood pressure, a leading cause of stroke, include:
  • measurement of blood pressure in adults at least every 2 years to screen for high blood pressure
  • weight control
  • physical activity
  • moderation in alcohol intake
  • moderate sodium intake
  • for those who smoke, quitting smoking
  • medications to treat high blood pressure if the person's blood pressure is over 140/90 after 3 months of these lifestyle modifications, or if the initial blood pressure is over 180/100
Other measures to reduce an individual's modifiable risk factors for stroke may include:
  • smoking cessation using nicotine patches, counseling, and formal smoking programs
  • control of blood sugar levels in a person with diabetes through medication, diet, and exercise
  • careful evaluation of asymptomatic carotid stenosis to determine the need for surgery
Carotid artery surgery, such as an endarterectomy or carotid stenting, may be indicated. An endarterectomy opens the narrow portion of the artery and increases the blood flow to the brain. People with carotid stenosis should also work closely with their healthcare professionals to control other risk factors for stroke.
  • semiannual screening of children with sickle cell anemia, using ultrasound to determine the child's risk of stroke
  • treatment of atrial fibrillation with blood thinners such as aspirin or warfarin, depending on the person's age and other risk factors
  • monitoring of high levels of total cholesterol or LDL, as well as low levels of HDL
Depending on the blood levels and the person's other risk factors, medications to lower cholesterol may be given.
Measures to reduce less well-documented or potentially modifiable risks for stroke may include:
  • weight reduction in overweight persons
  • 30 or more minutes of moderate exercise a day for most individuals. People with heart disease or disabilities should be in a medically supervised exercise program.
  • a healthy diet for heart disease, containing at least 5 fruits and vegetables a day
  • for those who drink alcohol, drinking in moderation. The AHA defines moderate drinking as no more than 2 drinks a day for men and 1 drink a day for women.
  • seeking treatment for drug abuse
  • monitoring of blood levels of homocysteine. For most individuals, a well-balanced diet following the food guide pyramid will provide enough folic acid and B vitamins to maintain a healthy homocysteine level. For people with elevated homocysteine levels, supplements containing folic acid and B vitamins may be recommended.
  • avoiding the use of oral contraceptives in women with other stroke risk factors
Some people have early warning signs that they are at risk for strokes. The most common warning sign is what is known as a transient ischemic attack (TIA). This is a type of reversible stroke that often goes away after a few minutes. These people can often get treatment that will prevent a stroke in the future. For instance, people may be advised to take aspirin or have carotid artery surgery to correct a blockage in a neck artery.

Diagnosed

How is the condition diagnosed?

Cranial MRIs and cranial CT scans may be ordered to show the type, size, and location of the stroke.
Blood tests may be done if the person is on blood-thinning medication. Blood flow tests using ultrasound or angiography may be used.

Long Term Effects

What are the long-term effects of the condition?

Strokes can cause death or permanent disability. Though many people recover some function in the first several months after a stroke, others show no improvement. Some people have several small strokes over time and slowly get worse with each one.

Other Risks

What are the risks to others?

Strokes are not contagious and pose no risk to others.

Treatments

What are the treatments for the condition?

If someone has the early warning signs of stroke, the emergency medical system should be contacted immediately. These signs include a sudden onset of:
  • severe headache
  • weakness or numbness of the face, arm, or leg, especially on one side of the body
  • dizziness
  • trouble walking or loss of balance, known as ataxia
  • confusion
  • speech impairments, including trouble speaking or understanding speech
  • visual impairments
Supportive therapy may also be needed with some strokes. This may include a ventilator (artificial breathing machine), and an artificial feeding tube if the person cannot swallow. Rehabilitation services can help to improve a person's function after a stroke. Physical therapy and other therapy, such as speech therapy or occupational therapy, may be used to maximize recovery.

Side Effects

What are the side effects of the treatments?

Side effects depend on the treatments used. For example, a ventilator may sometimes damage the lungs or cause an infection.

After Treatment

What happens after treatment for the condition?

After the person is stable, treatment of the risk factors for stroke, as well as the cause of the stroke, is important to prevent further strokes. For instance, anyone who smokes should stop, and blood pressure, blood sugar, and cholesterol levels must be controlled.
Many people need assistance of one form or another after a stroke. The need may range from a walking cane to 24-hour-a-day skilled nursing care. Ongoing therapy to improve function is usually advised for at least 6 months if the person is able.

Monitor

How is the condition monitored?

People having a stroke are often admitted to the hospital for close monitoring. Once the person is stable, he or she can often be sent home or to a skilled nursing facility or rehabilitation center for further therapy. Any new or worsening symptoms should be reported to the healthcare professional.

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