What is a hemorrhagic stroke?
Hemorrhagic stroke is a condition where the blood leaks from the ruptured brain vessels, killing or weakening the cells in that location.
Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are additional categories of hemorrhagic stroke (SAH). Stroke caused by hemorrhage is known to have high death rates and significant morbidity. The consequences are worse as the hemorrhagic stroke progresses. Given the typical rapid growth of bleeding, which results in a precipitous decline in consciousness and neurological dysfunction, early detection and treatment is crucial.
Because of the bulk effect of blood and the neurotoxicity of blood components and their breakdown products, the presence of blood in the brain parenchyma harms the tissue in its immediate vicinity. Secondary ischemia may result from tissue surrounding hematomas being compressed. A rapid increase in intracranial pressure that can result in herniation and death is the primary cause of a large portion of the early mortality from hemorrhagic stroke.
Ten to twenty percent of strokes each year are hemorrhagic strokes. In the United States of America, the United Kingdom, and Australia, hemorrhage occurs in strokes at a rate of 8–15%, while in Japan and Korea, it occurs at a rate of 18–24%.
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Around 12 to 15 percent of incidents per 100,000 people are reported each year. Asians and people from low- and middle-income nations are particularly affected. The prevalence rises with age and is more prevalent in men. The prevalence is rising worldwide, primarily in Asian and African nations. According to Japanese research, ICH is less common when hypertension is under control. In high-income nations, the case fatality rate ranges from 25 to 30 percent, while it ranges from 30 to 48 percent in low- to middle-income nations.
a) Non-modifiable risk factors or risk markers
- Family history of stroke
- Low birth weight
- Cerebral cavernous malformation
- Cerebral aneurysm
- Arterio-venous malformation (AVM)
NOTE : Cerebral cavernous malformation is a condition that occurs when the brain's capillaries, which are small blood vessels, accumulate, grow, and develop abnormal shapes that could impair blood flow.
Note : Cerebral aneurysm is a protrusion in the blood vessel's inner wall. The arterial wall might deteriorate when an aneurysm grows in size. A ruptured aneurysm could cause uncontrollable bleeding.
Note : In Arterio-venous malformation (AVM), the spine and brain are frequently impacted by this hereditary disorder. The blood arteries may burst if it happens in the brain, which could cause bleeding in the brain. This condition is uncommon.
b) Modifiable risk factors
- Hypertension is the single most important risk factor for ischemic stroke
- Atrial fibrillation is the most important and treatable cardiac cause of stroke
- Other cardiac diseases
- Diabetes is an independent risk factor
- Cigarette smoking
- Sickle cell disease
- Asymptomatic carotid stenosis
- Postmenopausal hormone therapy
- Lifestyle factors—associated with stroke risk
- Physical inactivity
Prevention of hemorrhagic stroke
Stroke cannot always be avoided, but some lifestyle adjustments may be beneficial.
These consist of:
- Avoiding or giving up smoking
- Keeping a healthy weight, doing regular exercise, eating a balanced diet, getting regular checkups, and taking steps to manage heart disease, diabetes, and other illnesses
- For those who have already experienced a stroke, these preventative actions are very crucial.
Clinical presentation of Stroke
- Weakness in one side of the body
- Inability to speak
- Loss of vision
- Vertigo. falling
- Severe headache only in hemorrhagic stroke
- Patients usually have multiple signs of neurologic dysfunction and the specific deficits are determined by the area of the brain involved. Hemi- or mono paresis occurs commonly, as does a Hemi sensory deficit.
- Patients with vertigo and double vision are likely to have posterior circulation involvement.
- Aphasia is seen commonly in patients with anterior circulation
- Stroke Patients also may suffer from dysarthria, visual field defects, and altered levels of consciousness.
- CT scan of the head will reveal an area of hyperintensity (white) in the area of hemorrhage and will be normal or hypo intense (dark) in the area of infarction. The CT scan may take 24 hours (and rarely longer) to reveal the area of infarction.
- MRI of the head will reveal areas of ischemia with higher resolution and earlier than the CT scan. Diffusion-weighted imaging (DWI) will reveal an evolving infarct within minutes.
- An electrocardiogram (ECG) will determine whether the patient has atrial fibrillation, a potent etiologic factor for stroke.
- Transthoracic echocardiography (TTE) will determine whether valve abnormalities or wall-motion abnormalities are sources of emboli in the brain. A “bubble test” can be done to look for an intraarterial shunt indicating an atrial septal defect or a patent foramen ovale.
A person who has had a hemorrhagic stroke may have several consequences, depending on the severity of the bleeding.
- Muscular tremor
- Reduced feeling, problems thinking
- Inability to speak or swallow, loss of bladder or bowel control
- Seizures and vision loss
- Issues with one’s mental health, such as depression
Additional issues include:
- Inhaling food or drink increases the chance of developing pneumonia.
- It can also cause brain enlargement within a week after having a stroke and blood clots that can cause deep vein thrombosis and perhaps pulmonary embolism.
- Infections of the urinary tract if the patient develops pressure sores from a catheter Shoulder discomfort caused by muscle weakness if the person is unable to move without assistance.
Treatment of hemorrhagic stroke
There are currently no standard pharmacologic strategies for treating intra-cerebral hemorrhage. Medical guidelines for managing blood pressure increased intracranial pressure, and other medical complications in acutely ill patients in neuro-intensive care units should be followed.
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Subarachnoid hemorrhage due to aneurysm rupture is associated with a high incidence of delayed cerebral ischemia in the 2 weeks after the bleeding episode. Vasospasm of the cerebral vasculature is thought to be responsible for the delayed ischemia and occurs between 4 and 21 days after the bleed. The calcium channel blocker nimodipine is recommended to reduce the incidence and severity of neurologic deficits resulting from delayed ischemia. Nimodipine 60 mg every 4 hours should be initiated on diagnosis and continued for 21 days in all subarachnoid hemorrhage patients. If hypotension occurs, it can be managed by reducing the dosing interval to 30 mg every 2 hours (same daily dose), reducing the total daily dose (30 mg every 4 hours), and maintaining intravascular volume and presser therapy
A surgical procedure known as a craniotomy may be necessary if there is brain swelling. A surgeon will make a small section of the skull to help relieve pressure on the brain that is building up due to the bleeding.
The importance of good medical care, nursing care, and rehabilitation is crucial.
Acute renal injury, gastrointestinal hemorrhage, urinary tract infection, cardiac arrhythmias, stress-induced cardiomyopathy, dysphagia, and aspiration are a few common issues. To avoid aspiration, a percutaneous endoscopic gastrostomy (PEG) may be required. In hemorrhagic stroke, ECG and cardiac enzyme testing are advised for myocardial ischemia screening. Deep vein thrombosis is decreased by intermittent pneumatic compression, however, the effectiveness of elastic stockings is questionable. To lessen disability, multidisciplinary rehabilitation is indicated. It is important to monitor blood sugar levels and take precautions against both hyperglycemia and hypoglycemia.