Stroke Victims: Can They Bleed Out?

A hemorrhagic stroke is a life-threatening medical condition that occurs when a blood vessel in the brain ruptures and bleeds. This can happen inside the brain (intracerebral hemorrhage) or between the brain and its outer covering layer (subarachnoid hemorrhage). Hemorrhagic strokes are severe and can quickly get worse, requiring immediate medical attention to avoid permanent brain damage or death. They make up about 10-20% of stroke cases and are caused by various factors, including high blood pressure, blood vessel abnormalities, and blood-thinning medications. The effects of a hemorrhagic stroke depend on its location and the amount of damage, with potential complications including thinking difficulties, swallowing problems, and mental health issues. Treatment focuses on controlling bleeding and reducing intracranial pressure through medication and, in some cases, surgery.

What is a hemorrhagic stroke?

A hemorrhagic stroke is a life-threatening medical condition that occurs when a weakened blood vessel in the brain suddenly ruptures and bleeds uncontrollably. This can happen inside the brain (intracerebral) or in the space between the brain and its outer covering layer (subarachnoid). Hemorrhagic strokes account for about 10% to 15% of all stroke cases and they are particularly severe due to the disruption of normal blood circulation in the brain. The accumulated blood from the rupture puts pressure on the surrounding brain tissue, causing damage or destruction.

There are two main types of hemorrhagic strokes: intracranial hemorrhages and subarachnoid hemorrhages. Intracranial hemorrhages occur when bleeding takes place inside the brain, putting pressure on the surrounding brain tissue from within. On the other hand, subarachnoid hemorrhages happen when bleeding occurs between the brain and the membranes that cover it, causing pressure on the brain from outside.

The signs and symptoms of a hemorrhagic stroke are often sudden and severe, and they can get worse quickly. These may include sudden numbness or weakness on one side of the body, trouble speaking or understanding language, sudden trouble seeing, walking, or maintaining balance and coordination, and a severe headache with no known cause. Other symptoms include sensitivity to light, stiffness in the neck or neck pain, fluctuations in heart rate and breathing, and difficulty swallowing.

The most common cause of hemorrhagic strokes is high blood pressure, especially when it is very high or sustained for long periods. Other causes include blood vessel abnormalities such as arteriovenous malformations, blood or bleeding disorders like sickle cell anemia, and conditions such as moyamoya disease or cerebral amyloid angiopathy. Certain medications, such as blood thinners, can also increase the risk of hemorrhagic strokes.

Prompt medical attention is critical for hemorrhagic strokes to prevent permanent brain damage or death. Treatment options include interventional radiology, neurosurgical procedures, and medications to reduce swelling, prevent seizures, and manage pain. The goal of treatment is to prevent life-threatening complications, reduce disability, and help the patient regain as much normal functioning as possible through rehabilitation.

What are the different types of hemorrhagic stroke?

Hemorrhagic strokes are caused by uncontrolled bleeding inside the brain or in the space between the brain and its outer covering layer. They account for about 10% to 15% of all strokes and are particularly severe and life-threatening as they can quickly get worse and cause permanent brain damage or even death.

There are two main types of hemorrhagic strokes:

Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) occurs when there is bleeding inside the brain, putting pressure on the surrounding brain tissue from within. It is usually caused by high blood pressure and can be severe enough to cause a coma or death. ICH can be further categorised into:

• Hypertension-induced ICH: This is caused by longstanding hypertension, which damages the arteries and can lead to rupture.
• Cerebral amyloid angiopathy (CAA): This is an important cause of primary lobar intracerebral bleeding in older adults, characterised by the deposition of amyloid-β peptide in the capillaries and arteries in the brain.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) occurs when bleeding happens in the subarachnoid space, which is the area between the brain and the membranes covering it. This type of hemorrhage is often due to an aneurysm or an arteriovenous malformation (AVM). An aneurysm is a weakened, ballooned area on an artery wall that has a high risk of rupturing. AVM, on the other hand, is a congenital disorder consisting of a tangled web of arteries and veins that bypasses normal brain tissue.

What are the symptoms of a hemorrhagic stroke?

A hemorrhagic stroke is a life-threatening medical condition that occurs when a weakened blood vessel in your brain ruptures and bleeds. This can happen in one of two ways: intracerebral hemorrhage (bleeding inside the brain) or subarachnoid hemorrhage (bleeding between the brain and its outer covering). The effects of a hemorrhagic stroke can be severe and quick, requiring immediate medical attention to prevent permanent brain damage or even death.

• Sudden, severe headaches, often described as "thunderclap" headaches.
• Sensitivity to light, also known as photophobia, where bright lights trigger severe pain.
• Dizziness, loss of balance, or vertigo.
• Nausea and vomiting.
• Fainting or loss of consciousness.
• Aphasia, or difficulty with speech, including slurred or garbled speech.
• Partial or total loss of movement or sensation, typically on one side of the body.
• Paralysis of one side of the body.
• Loss of vision or other senses.
• Confusion, irritability, or loss of alertness.
• Stiffness or pain in the neck or shoulders.
• Fluctuations in heart rate and breathing.
• Difficulty swallowing.
• Abnormal taste in the mouth.
• Seizures.

It is important to recognize these warning signs and act quickly by calling emergency services. The faster a person receives medical care, the better their chances of recovery and survival.

How is a hemorrhagic stroke diagnosed?

A hemorrhagic stroke is a life-threatening medical condition that occurs when a weakened blood vessel in the brain ruptures and bleeds. This can happen inside the brain (intracerebral) or between the brain and its outer covering (subarachnoid). As a result, the affected area of the brain is starved of oxygen, and the accumulated blood puts pressure on the surrounding brain tissue, causing severe symptoms that get worse quickly.

Diagnosis of a hemorrhagic stroke is based on a thorough medical history and physical exam. Doctors may suspect bleeding inside the skull based on the patient's symptoms, which can include:

• Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
• Sudden trouble speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking
• Sudden dizziness, loss of balance, or coordination
• A sudden, severe headache with no known cause
• Loss of consciousness

In addition to a medical history and physical exam, several tests can be used to diagnose a hemorrhagic stroke:

Neurological Examination:

Because many people who experience a hemorrhagic stroke are unconscious, providers will test certain reflexes and look for changes in processes that the patient cannot deliberately control, such as how their pupils react to light.

Imaging Tests:

• Computerized Tomography (CT) Scan: This is the initial investigation of choice and is considered the "gold standard" in detecting acute hemorrhage due to its sensitivity.
• Magnetic Resonance Imaging (MRI) Scan: Gradient echo and T2 susceptibility-weighted MRI have the same sensitivity as CT scans for detecting acute hemorrhage and are more sensitive for identifying prior hemorrhage.
• Computed Tomographic Angiography (CTA): A special contrast material (dye) is injected into a vein, and images are taken of the blood vessels to look for abnormalities.
• Magnetic Resonance Angiography (MRA): Patients are placed on a table that slides into a magnetic resonance scanner, and the blood vessels are imaged to detect cerebral aneurysms.
• Cerebral Angiogram: A small tube (catheter) is inserted through a blood vessel, usually in the leg, and guided into the blood vessels in the neck that go to the brain. Contrast dye is then injected, and pictures are taken to identify the exact location, size, and shape of aneurysms.

Laboratory Tests:

• Blood Tests: These are done to check for signs of infection or heart damage, clotting ability and blood sugar levels, and how well the kidneys and liver are functioning.
• Electrocardiogram (ECG or EKG): This test is done to ensure that a heart issue is not the source of the problem.

In summary, the diagnosis of a hemorrhagic stroke involves a comprehensive approach, including a detailed medical history, physical examination, and the use of advanced imaging and laboratory techniques to confirm the presence of bleeding in the brain and determine the best course of treatment.

How is a hemorrhagic stroke treated?

Hemorrhagic strokes are often difficult to treat because the affected area is hard to reach directly. This means that it is often impossible to stop the bleeding directly. Instead, the top priority is to reduce the amount of bleeding or stop it entirely by boosting the body's clotting processes and lowering blood pressure. In some cases, surgery may also be necessary.

• Lowering blood pressure: As high blood pressure is the most common cause of hemorrhagic strokes, a priority for treating these strokes is to lower blood pressure and keep it at a safe level. This can be done using beta-blockers, ACE inhibitors, calcium channel blockers, or hydralazine.
• Boosting the body's clotting processes: In some cases, the body's ability to form a clot may not work as it should. In these cases, the priority is to support the body's hemostasis processes and make them more effective. This can be done through the infusion of medications or blood factors that make it easier for clotting to happen, such as vitamin K therapy, prothrombin or clotting factor infusions, and more.
• Surgery: In some cases, emergency surgery may be necessary to remove the accumulated blood and relieve the pressure buildup on the brain. Surgical treatments include craniotomy, decompressive craniectomy, stereotactic aspiration, endoscopic aspiration, and catheter aspiration.
• Medications: After a procedure, medications may be given to reduce blood pressure, pain, anxiety, headaches, and seizures.
• Stroke rehabilitation: Different types of therapy and rehabilitation can be helpful for people recovering from a stroke. Speech therapy, physical therapy, and cognitive therapy can help improve muscle strength and control, as well as strengthen mental abilities.

The treatments for hemorrhagic strokes depend on where the stroke is in the brain, how severe it is, and many other factors.

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