HEMORRHAGIC STROKE Definition: Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue

Alternative Names: Brain bleeding Brain hemorrhage Stroke hemorrhagic Causes, incidence, and risk factors: Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly, either because of the presence of the blood itself, or because the fluid increases pressure on the brain and harms it by pressing it against the skull. Bleeding irritates the brain tissue, causing swelling. The surrounding tissues of the brain resist the expansion of the bleeding, which is finally contained by forming a mass (hematoma). Both swelling and hematoma will compress and displace normal brain tissue. Symptoms: Stroke symptoms are typically of sudden onset and may quickly become worse. The following is a list of possible problems: Weakness or inability to move a body part Numbness or loss of sensation Decreased or lost vision (may be partial) Speech difficulties Inability to recognize or identify familiar things Sudden headache Vertigo (sensation of the world spinning around) Dizziness Loss of coordination Swallowing difficulties Sleepy , stuporous , lethargic , comatose , or unconscious

Signs and tests: A neurologic exam is almost always abnormal. The patient may look drowsy and confused. An eye examination may show abnormal eye movements, and changes may be seen upon retinal examination (examination of the back of the eye with an instrument called ophthalmoscope). The patient may have abnormal reflexes. However, these findings are not specific to brain hemorrhage. The most important test to confirm the presence of a brain hemorrhage is a CT scan, which provides pictures of the brain. A CT scan should be obtained without delay. 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 identify aneurysms or AVM. Other tests may include:
CBC

Bleeding time Prothrombin / partial thromboplastin time (PT/PTT) CSF (cerebrospinal fluid) examination (rarely needed) Treatment: Treatment includes life-saving measures, relieving symptoms, repairing the cause of the bleeding, preventing complications, and starting rehabilitation as soon as possible. Recovery may occur over time as other areas of the brain take over functioning for the damaged areas. Immediate treatment: Treatment is ideally administered in an intensive care unit, where complications can immediately be detected. Medical personnel pay careful attention to breathing because sometimes persons with brain hemorrhage develop very irregular breathing patterns or even stop breathing entirely. A person having a hemorrhagic stroke may be unable to protect the airway during coughing or sneezing because of impaired consciousness. Saliva or other secretions may go "down the wrong pipe," which is potentially serious and may cause lung problems such as aspiration pneumonia. To treat or prevent these breathing problems, a tube may need to be placed through the mouth into the trachea to start mechanical ventilation. The blood pressure may be too high or too low in patients with brain hemorrhage. These problems need to be addressed immediately by doctors. In addition, brain bleeding may cause swelling of surrounding brain tissue, and this may require therapy with some drugs called hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions). Bedrest may be advised to avoid increasing the pressure in the head (intracranial pressure). This may include avoiding activities such as bending over, lying flat, sudden position changes or similar activities. Stool softeners or laxatives may prevent straining during bowel movements (straining also causes increased intracranial pressure). Medications may relieve headache but should be used with caution because they may reduce consciousness. This may produce the wrong impression that the patient is getting worse. Antihypertensive medications may be prescribed to moderately reduce high blood pressure. Medications such as phenytoin may be needed to prevent or treat seizures. Nutrients and fluids may need to be supplemented if swallowing difficulties are present. This can be intravenous or through a feeding tube into the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

Surgery: Sometimes, surgery is needed to save the patient's life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. For example, a hemorrhage due to an aneurysm requires special treatment (see aneurysm). For other types of bleeding, removal of the hematoma may occasionally be needed, especially when bleeding occurs in the back of the brain. Some physicians are currently investigating whether the injection of a "clot buster" inside the hematoma can facilitate the removal of brain hemorrhages through needles or catheters, allowing less invasive surgery. Long term treatment: Recovery time and the need for long-term treatment are highly variable in each case. Physical therapy may benefit some patients. Activity should be encouraged within the person's physical limitations. Alternative forms of communication such as pictures, verbal cues, demonstration or others may be needed depending on the type and extent of language deficit. Speech therapy, occupational therapy, or other interventions may increase the ability to function. Urinary catheterization or bladder or bowel control programs may be required to control incontinence. A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show a marked indifference or lack of judgment, which increases the need for safety precautions. Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke. Complications Pressure sores Permanent loss of movement or sensation of a part of the body Joint contractures Muscle spasticity Permanent loss of cognitive or other brain functions (dementia) Disruption of communication, decreased social interaction Decreased ability to function or care for self Decreased life span Urinary and respiratory tract infections

Prevention: Most cases of hemorrhagic stroke are associated with specific risk factors, such as high blood pressure, smoking, or cocaine use. Controlling blood pressure and avoiding smoking and cocaine can reduce the

chances of brain bleeding. Surgery to correct blood vessel abnormalities like aneurysms or AVMs is sometimes advisable to prevent bleeding.