Haemorrhagic stroke

• What is Haemorrhagic Stroke?
• Statistics
• Risk Factors
• Progression
• Symptoms
• Clinical Examination
• How is it Diagnosed
• Prognosis
• Treatment
• References

What is Haemorrhagic Stroke?

Haemorrhagic stroke is characterised by bleeding occuring directly into the brain itself, damaging adjacent brain tissue. This often results from rupture of a vessel due to hypertension or an aneurysm (abnormal dilation or weakness of a vessel).

Statistics

The majority of strokes occur in patients greater than 55 years of age.
Surveys suggest that stroke of all types, affect 1.2% of Australia’s population corresponding to over 200,000 patients affected. At current trends, with growing levels of inactivity and obesity, this number is predicated to skyrocket by the year 2050. Hemorrhagic stroke accounts for 10-15% of stroke cases and these types of stroke tend to produce more severe outcomes.
Men
Men are at greater risk of stroke than women up until the age of 55 years, after which both sexes have similar risks. Stroke is a major cause of morbidity and mortality in the elderly.
Women
Whilst stroke is considered a disease more commonly affecting men, women are actually twice as likely to die from stroke than men. In addition, females have additional risk factors for stroke such as oral contraceptives, that are not present in men. The overall global incidence of stroke is not known but it is considered a leading killer and disabler, being the third most common cause of death and the first leading cause of disability.
Children
Stroke is uncommon in children accounting for only a small percentage of stroke cases each year. Stroke in children is often secondary to congenital heart disease, genetic disorders, abnormalities of vessels within the brain or blood disorders. Half of strokes in children are haemorrhagic and these may be associated with long term disabilities.

Risk Factors

On most occasions the leading cause of a haemorrhagic stroke is high blood pressure. The high blood pressure itself stresses the arterial walls within the brain until they break. Another cause of hemorrhagic stroke is an aneurysm. An aneurysm is described as a weak spot that exists within the arterial wall which, when put under high blood pressure, can balloon outward. Eventually this weak spot will burst leading to a stroke and further complications.
Stroke can also be caused by the accumulation of a protein called amyloid within the artery walls, particularly in elderly patients. This makes the arteries more prone to bleeding and reduces their overall reliability and strength.

Symptoms

• Haemorrhagic stroke may be clinically indistinguishable from ischaemic (meaning lack of blood flow) stroke.
• Hypertension commonly is the main cause of hemorrhagic stroke.
• A coma is more common with hemorrhagic strokes than with ischemic strokes.
• Patient’s symptoms vary according to the area of brain affected.
• Many patients have symptoms of increased intracranial pressure such as headache and nausea.

Clinical Examination

The doctor will examine you to determine whether a stroke is likely to have occurred or if it is some other disorder mimicking stroke. The likely cause of the stroke will also be sought. Examination will include blood pressure measurements, head and neck examination looking for possible trauma, complete neurological examination and cardiovascular examination (including the heart, backs of the eyes and peripheral blood vessels searching for a possible cause). Patients may experience:

• Altered level of consciousness due to raised intrascranial pressure.
• Weakness or inability to move a body part.
• Numbness, loss of sensation.
• Impaired or lost vision.
• Inability to recognize or identify familiar things.
• General Dizziness.
• Difficulty swallowing.
• Loss of coordination.
• Vertigo.
• Difficulty speaking- If the dominant hemisphere (usually left) is affected, the patient may have aphasias and language difficulties.

How is it Diagnosed

A neurological exam is conducted immediatley on suspicion of a stroke and is almost always abnormal. Patients may appear drowsy, lethargic and confused.
An eye examination may show abnormal eye movements, and changes may be seen on retinal examination. Co-ordination and general reflexes may also be impaired. Having said this however, these findings are not specific solely to this form of stroke.
The most important test to confirm the presence of a brain hemorrhage is a CT scan and should be obtained as soon as possible.
A brain magnetic resonance imaging (MRI) scan can also be obtained later to better understand what caused the bleeding.
A conventional angiography (x-ray of the arteries using dye) may be required to demonstrate aneurysms and/or arterio-venous malformations (abnormal connections or dilations of vessels).

Prognosis

Around one quarter of men and women who suffer a stroke die as a result of the stroke or its complications, a further half have long-term disabilities, and about one-forth recover most or all function. Haemorrhagic stroke is considered less common, but is on average more frequently fatal than ischaemic stroke.

Treatment

Treatment includes life-saving measures, relief of symptoms, repair of the cause of the bleeding, prevention of complications, and start of rehabilitation as soon as possible. Recovery may occur over time as other areas of the brain take over functioning for the damaged areas.

More information

For more information on how international trials are using CT scans to predict and improve stroke outcomes, please see Professor Lesley Cala’s video on Improving Stroke Outcomes.

 

References

1. AIHW- Stroke, Cardiovascular Health, 2005.
2. Brott T, Thalinger K, Hertzberg V: Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke 1986 Nov-Dec; 17(6): 1078-83.
3. Cotran, Kumar, Collins. Robbins Pathological Basis of Disease. 6th edition. W.B. Saunders Company, 1999.
4. Kumar, Clark. Clinical Medicine. Fifth Ed. W.B. Saunders, 2002.
5. Longmore, Wilkinson, Rajagopalan. Oxford Handbook of Clinical Medicine. Sixth Ed. Oxford University Press, 2004.
6. Nassisi. Stroke, Hemorrhagic. eMedicine. Web MD, 2005. [Available online at http://www.emedicine.com/emerg/topic557.htm]