Hemorrhagic strokes are caused by the breakage or “blowout” of a blood vessel in the brain, as known as a hemorrhage. Hemorrhages can be caused by a number of disorders that affect the blood vessels, including; long-standing high blood pressure, arteriovenous malformations, and cerebral aneurysms. There are two types of hemorrhagic stroke: intracerebral and subarachnoid.
Intracerebral Hemorrhage (ICH)
In an ICH, bleeding occurs from the tiny arteries, or vessels, deep within the brain itself. Common causes of ICH include hypertension (high blood pressure) and blood-thinning medications, that can cause these thin-walled arteries to rupture and release blood into the brain tissue. As the blood collects and forms a clot, or hematoma, it can grow and put pressure on surrounding brain tissue. As blood spills into the brain, the area of the brain that artery supplied is now deprived of oxygen blood, resulting in a stroke. As blood cells within the clot die, toxins are released that further damage brain cells in the area surrounding the hematoma.
Signs and Symptoms
Signs and symptoms of an ICH include: confusion, loss of consciousness, headache, vision changes, numbness/tingling sensation in arm or leg, slurred or garbled speech and/or facial droop.
When diagnosing a stroke, physicians work quickly to acquire a complete medical history. This includes the patient’s symptoms, current and previous medical problems, medications the patient is currently taking, and family history. A physical exam also is conducted.
To help determine the source and location of bleeding, physicians rely on diagnostic tests such as computed tomography (CT) and computed tomography angiography (CTA). Both of these scans are noninvasive X-rays that enable physicians to review the anatomical structures within the brain to determine whether or not blood is present. The CT scan is a rapid and easy way to determine the location, size, and pattern of the blood as well as any compression of the surrounding brain tissue. The CTA scan is specifically designed to look at the blood vessels within the brain and helps determine if the ICH was caused by a vascular malformation.
A magnetic resonance imaging (MRI) scan, another noninvasive test, uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues of your brain. Much like the CTA, a magnetic resonance angiogram (MRA) provides visualization of the blood vessels and structures of the brain.
An angiogram is an invasive procedure in which a catheter is inserted into an artery and passed through the blood vessels to the brain. Once the catheter is in place, a contrast dye is injected into the bloodstream to illuminate the blood vessels.
Depending on the size, location and the cause of bleeding, ICH’s can be managed either surgically or medically.
The goal of surgery is to remove as much of the blood clot as possible and stop the source of bleeding if it is from an identifiable cause such as an AVM, aneurysm, or tumor. Depending of the location of the clot either a craniotomy or a stereotactic aspiration may be performed.
Craniotomy involves cutting a hole in the skull with a drill to expose the brain and remove the clot. Because of the increased risk to the brain, this technique is usually used only when the hematoma is close to the surface of the brain or if it is associated with an AVM or tumor that must be removed.
Stereotactic Aspiration is a less invasive technique preferred for large hematomas located deep inside the brain. The procedure requires attaching a stereotactic frame to the head with four pins. A small metal cage is placed over the frame. Next, a CT scan is obtained to help the surgeon pinpoint the exact coordinates of the hematoma. Then the surgeon drills a small hole about the size of a quarter in the skull. With the aid of the stereotactic frame, a hollow needle is passed through the hole, through the brain tissue, directly into the clot. The hollow needle is attached to a large syringe, which the surgeon uses to suction out as much of the clot as possible.
Initial monitoring and management of patient with an ICH will typically occur in the neuro-intensive care unit. This alloss for close and careful observation of blood pressure control, seizure activity, blood sugar, vital signs, and respiratory status.
An ICH causes brain tissue damage, compression on surrounding structures, and a shift in the brain matter. These can all cause an increase in the intracranial pressure (ICP) or pressure inside the brain. Increased ICP will cause worsening of the neurological exam and compromise of the respiratory system. Frequent neurological and respiratory assessments will be preformed in the ICU. Respiratory assistance via a breathing tube and ventilator may be required to support oxygenation.
Medical management for an ICH begins with blood pressure control to help prevent re-bleeding and expansion of the ICH. Blood pressure is typically kept <160/90 using intravenous and oral anti-hypertensive medications. Precautions are taken to prevent very low blood pressures, hypotension, which may lower blood flow to the brain. Achieving long-term blood pressure control may require the patient to be discharged on a new blood pressure medication or regimen. Follow-up with an internal medicine or primary care provider is important in maintaining good blood pressure control and helps to prevent future ICH.
A potential complication of an ICH is seizure activity. In the intensive care unit, the patient will be closely monitored for seizures and often times a short course of preventative anti-seizure medications will be administered.
High blood sugars can be seen in the diabetic and non-diabetic patients. While hospitalized, blood sugar will be monitored and treated with insulin therapy.
Pain is managed with oral or intravenous medications to promote comfort and healing.
To promote healing, proper nutrition is begun early during the patient’s hospital stay to Depending on the size and location of the ICH, some patients may not be alert enough to eat or unable to chew and swallow food safely. Speech therapists assess the ability to swallow and take in adequate nutrition. Stomach feeding tubes can be used for patients who are unable to eat on their own, and nasal feeding tubes can be used a short-term alternative. If long-term feeding is required, a percutaneous endoscopic gastrostomy tube (PEG tube) can also be used.
When the patient’s condition is medically stable, early mobilization with therapy will be initiated to prepare for long term needs once discharged from the hospital