Effective Hemorrhagic Stroke Treatments: What You Need To Know

Hemorrhagic strokes are medical emergencies that occur when a blood vessel in the brain breaks and bleeds. They require immediate treatment and can be fatal. The two main treatments for hemorrhagic strokes are medications and surgery.

Medications can be used to support clotting and manage blood pressure. Surgery can be used to remove the accumulated blood, relieve pressure on the brain, and repair an aneurysm.

Other treatments include stereotactic radiosurgery and reducing pressure on the brain by elevating the patient's head.

Lowering blood pressure

Hypertension can cause blood vessels in the brain to rupture and bleed, and the bleeding disrupts normal circulation, adding extra pressure inside the brain, which can damage or kill brain cells.

The two main treatments for hemorrhagic stroke are medications and surgery. Medications can help to increase the body's ability to stop the bleeding in the brain and keep blood pressure at a safe level. Antihypertensive agents are used to reduce blood pressure and other risk factors for heart disease.

The American Heart Association/American Stroke Association (AHA/ASA) has provided the following recommendations for treating elevated blood pressure:

• If systolic blood pressure is over 200 mm Hg or mean arterial pressure is over 150 mm Hg, then consider aggressive reduction with continuous IV infusion and check blood pressure every 5 minutes.
• If systolic blood pressure is over 180 mm Hg or mean arterial pressure is over 130 mm Hg and intracranial pressure may be elevated, then consider monitoring intracranial pressure and reducing blood pressure using intermittent or continuous IV medications, while maintaining a cerebral perfusion pressure of 60 mm Hg or higher.
• If systolic blood pressure is over 180 or mean arterial pressure is over 130 and there is no evidence of elevated intracranial pressure, then consider a modest reduction in blood pressure (target mean arterial pressure of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous IV medications, and perform a clinical re-examination of the patient every 15 minutes.
• In patients presenting with a systolic blood pressure of 150 to 220, acute lowering of systolic blood pressure to 140 mm Hg is probably safe.

For patients with aneurysmal subarachnoid hemorrhage, the AHA/ASA guidelines recommend lowering blood pressure below 160 mm Hg acutely to reduce rebleeding.

According to the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP), physicians should start treatment for patients who have persistent systolic blood pressure at or above 150 mm Hg to achieve a target of less than 150 mm Hg to reduce the risk of stroke, cardiac events, and death.

In the acute setting, suggested agents for use include beta-blockers (e.g. labetalol) and angiotensin-converting enzyme inhibitors (e.g. enalapril). For more refractory hypertension, agents such as nicardipine and hydralazine are used.

A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. However, the blood pressure goal in acute ischemic stroke is uncertain and probably depends on the time window of treatment and the use of revascularization therapy.

Surgery to repair an aneurysm

There are several surgical options for repairing an aneurysm:

Surgical Clipping

This procedure involves placing a tiny clamp or clip at the base of the aneurysm to stop blood flow to it and prevent it from bursting or bleeding again.

Angioplasty and Stents

In this procedure, a surgeon threads a catheter through an artery in the groin to the carotid arteries. A balloon is then inflated to expand the narrowed artery, and a stent is inserted to support the opened artery.

Endovascular Embolization

This procedure involves placing a catheter inside the blood vessels and blocking the abnormal vessels with materials such as glue or coils.

Cerebral Angiogram

This test is used to identify the exact location, size, and shape of aneurysms and can be useful for mapping out a treatment plan. 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 detect abnormalities.

Microsurgery

Microsurgery may be recommended if the aneurysm has bled or is located in an easily accessible area of the brain. It involves the use of a microscope and small, precise instruments to work on small structures in the brain.

Coil Embolization

In this minimally invasive procedure, a catheter is directed through the blood vessels into the aneurysm. Using X-ray guidance, the surgeon carefully places soft platinum micro-coils into the aneurysm and detaches them. The coils act as a mechanical barrier to blood flow, sealing off the aneurysm.

The choice of surgical procedure depends on various factors, including the size, location, and shape of the aneurysm, as well as the patient's overall medical condition and symptoms. It is important to consult with experts in the field, including cerebrovascular neurosurgeons, neurointerventionalists, and neuroradiologists, to determine the best treatment approach.

Surgery to remove an arteriovenous malformation

There are several treatment options for AVMs, including careful monitoring, endovascular embolization, stereotactic radiosurgery (also known as Gamma Knife surgery), and microvascular neurosurgery. The best treatment option is determined based on the location of the AVM, patient symptoms, health, and other risks. Surgery to remove the AVM involves making a small cut near the AVM, sealing the surrounding arteries and veins to prevent bleeding, and then removing the AVM. The surgeon redirects blood flow to normal blood vessels, curing the condition. Patients will also have a brain scan to ensure the AVM has been fully removed and may have a short hospital stay and undergo short-term rehabilitation.

Possible side effects of AVM surgery include numbness or slow movement, problems with speech or memory, and a small risk of hemorrhage. Recovery from AVM surgery can take two to six months, and patients will need to care for their incision and manage any swelling or bruising around the eyes following the procedure.

Stereotactic radiosurgery

The annual rate of total obliteration of AVMs following stereotactic radiosurgery is 56% in the first three years, rising to 82% after ten years. However, the presence of a patent aneurysm increases the risk of re-hemorrhaging after stereotactic radiosurgery.

Reducing pressure on the brain

Elevating the Patient's Head

The patient's bed is elevated at a 30-degree angle. This simple yet effective measure helps relieve pressure on the brain by promoting cerebrospinal fluid drainage and improving venous blood flow.

Osmotic Agents

Osmotic agents, such as mannitol (20% solution) and hypertonic saline, are administered to reduce brain swelling and oedema. These agents work by drawing water out of the brain tissue, thereby decreasing intracranial pressure.

Hyperventilation

In cases of severe intracranial pressure elevation, hyperventilation may be induced after intubation and sedation. This involves increasing the rate and depth of breathing to reduce carbon dioxide levels in the blood, which in turn constricts blood vessels in the brain and decreases blood flow, reducing intracranial pressure.

Intracranial Pressure Monitoring

In patients with a decreased level of consciousness, intracranial pressure (ICP) monitoring is recommended. This involves inserting a catheter into the brain to directly measure ICP and guide treatment decisions. The goal is to maintain cerebral perfusion pressure (CPP) within an optimal range of 50 to 70 mmHg.

Decompressive Craniectomy

In cases of large hematomas and significant brain swelling, decompressive craniectomy may be performed. This involves temporarily removing a section of the skull to create more space and reduce intracranial pressure. This procedure can be life-saving and may improve long-term functional outcomes.

Medical Management of Brain Swelling

In addition to the measures mentioned above, medical treatments to control brain swelling are also employed. These may include corticosteroids and other anti-inflammatory medications to reduce oedema and inflammation, respectively.

The primary goal of these interventions is to alleviate pressure on the brain, prevent further damage to brain tissue, and improve the patient's chances of recovery and survival. Each case of hemorrhagic stroke is unique, and the specific interventions used will depend on the patient's condition and the judgement of the treating physicians.

Frequently asked questions