What is a hemorrhagic stroke?

DEAR DOCTOR K:

My grandfather just had a hemorrhagic stroke and is in pretty bad shape. What is it, and how is it treated?

DEAR READER:

I’m sorry to hear this, but there’s a chance he’ll make a good recovery. There are two major kinds of strokes. In the most common type, a blockage in one of the brain’s arteries shuts off the blood supply to a part of the brain. That’s called an ischemic (is-KEE-mic) stroke.

A hemorrhagic stroke occurs when one of the brain’s arteries bursts and spills blood into the surrounding tissue. This can create pressure inside the skull that damages the brain. The spilled blood can also provoke arteries to clamp down, and the reduced blood flow to the brain causes further damage. Without immediate treatment, a hemorrhagic stroke can cause disability or death.

Hemorrhagic strokes, like all strokes, are an emergency. The immediate treatment goal is to prevent a second hemorrhage and to stop any more bleeding from the initial rupture. The options are a procedure called coiling, surgery or medication. The cause and location of the bleeding, either inside the brain (intracerebral) or on its surface (intracranial), helps determine treatment.

Some hemorrhagic strokes are caused by a ruptured aneurysm. An aneurysm is a weak spot in a blood vessel wall. Coiling can prevent an aneurysm from causing a second hemorrhage. In this procedure, the surgeon inserts a catheter into an artery and works it up to the aneurysm in the brain. The doctor releases a tiny coiled ball inside the aneurysm. The coil makes the blood in the aneurysm clot. Once this happens, the aneurysm is no longer dangerous. (See illustration below.)

A coiling procedure

Illustration of coiling procedure

 

Surgical procedures may also be used to prevent a second hemorrhage. For example, in another treatment for hemorrhagic stroke caused by an aneurysm, a surgeon may open the skull, clamp the base of the aneurysm to keep it from bleeding any more and remove the accumulated blood. Removing blood is particularly important when heavy bleeding has produced increased pressure in the brain.

In addition to reducing the risk of re-bleeding, surgery must wash clotted blood away from the artery. Clotted blood can cause constriction of arteries at the base of the brain. This can be so severe that it can even cause death.

Drug therapy for hemorrhagic stroke involves medications to control blood pressure that is too high or too low, or to reduce brain swelling. (High blood pressure is a major cause of hemorrhagic stroke.)

People like your grandfather with hemorrhagic strokes often are severely affected at first. But if they receive medical care quickly and escape the dire consequences of the first hours after the stroke, they can actually recover a lot of brain function.

Perhaps the most famous U.S. citizen to suffer a hemorrhagic stroke was President Franklin D. Roosevelt in 1945. Back then, there were no potent medicines to control his blood pressure, and brain surgery (which began here at Harvard) was a very young field. Unfortunately, within hours he was gone. His odds for recovery today would be far greater. And with today’s blood pressure medicines, he might well never have had the stroke in the first place.