How The Treatment Of An Ischemic Stroke May Lead To Brain Bleed
When we look at what causes bleeding after a stroke, it is easy to see why the treatment of an ischemic stroke may lead to brain bleed. The goal of treatment of a regular stroke is to get rid of the blockage and get blood flowing again into the part of the brain affected by the stroke. If the blood gets there after the walls of the blood vessels have already been damaged, there is a risk of them bleeding into the brain.
The risk of brain bleed goes up as the time needed to successfully restore the blood flow gets longer. As more time passes, the part of the brain without blood gets more damaged and more likely to have blood vessels with damaged walls. The risk of brain bleed after treatment is one of the reasons why it is important to call 911 as soon as you suspect a stroke. If they are able to get the blood flowing again within 3 hours, the risk of brain bleed after treatment is low.
How Is A Diagnosis Made
When a person is brought to the emergency room with a suspected brain hemorrhage, doctors will learn as much about his or her symptoms, current and previous medical problems, medications, and family history. The person’s condition is assessed quickly. Diagnostic tests will help determine the source of the bleeding.
Computed Tomography scan is a noninvasive X-ray to review the anatomical structures within the brain and to detect any bleeding. CT angiography involves the injection of contrast into the blood stream to view arteries of the brain.
Angiogram is an invasive procedure, where a catheter is inserted into an artery and passed through the blood vessels to the brain. Once the catheter is in place, contrast dye is injected into the bloodstream and X-rays are taken.
Magnetic resonance imaging scan is a noninvasive test, which uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues of your brain. An MRA involves the injection of contrast into the bloodstream to examine the blood vessels as well as the structures of the brain.
Can People Recover From Brain Hemorrhages And Are There Possible Complications
How well a patient responds to a brain hemorrhage depends on the size of the hemorrhage and the amount of swelling.
Some patients recover completely. Possible complications include stroke, loss of brain function, seizures, or side effects from medications or treatments. Death is possible, and may quickly occur despite prompt medical treatment.
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What Does A Small Bleed On The Brain Mean
Brain bleeding can occur as a result of an accident, a brain tumor, a stroke, or excessive blood pressure caused by congenital or other health issues. Brain bleed can limit oxygen flow to the brain, increase intracranial pressure, and destroy brain cells. However most cases of brain bleeding are due to accidents that happen during sports activities, acts of violence, or when taking certain medications. This type of injury requires medical attention immediately after it occurs.
Small bleeds may not cause any symptoms at all. You may feel weak, have trouble speaking properly, or show other signs of confusion. These may be the first signs that you’re experiencing another problem with your brain function. It’s important to visit with your doctor if you experience any changes in behavior or ability to think clearly. He or she may want to perform some tests to determine the cause of your symptoms.
Large bleeds can lead to serious complications. Symptoms include loss of consciousness, paralysis, speech problems, vision problems, and abnormal movements. Emergency treatment is necessary for anyone experiencing these symptoms after an accident. A physician should be contacted immediately if you have a history of heart disease or high blood pressure.
Management Of Venous Thromboembolism
ICH patients are at high risk for thromboembolic complications . Several studies have shown the efficacy of intermittent pneumatic compression and the inefficacy of graduated compression stockings in reducing deep venous thrombosis in ICH patients . Although historically there has been reluctance to use heparin early after ICH for fear of worsening intracranial bleeding, low-dose unfractionated heparin and LMWH have both shown safety in reducing the incidence of pulmonary embolism without affecting ICH hematoma volume . LMWH or unfractionated heparin for DVT or PE prophylaxis may be considered in immobile ICH patients after demonstration of hematoma stabilization 14 days after onset according to the 2015 AHA/ASA ICH guidelines . There are very few data regarding the management of DVT and PE in ICH patients, but treatment with anticoagulation or inferior vena cava filter placement is probably indicated . Factors that should be taken into consideration before treating are the time of onset of ICH, its location , hematoma stability, and the patient’s general condition .
Mohamed El-Dib, Janet S. Soul, in, 2019
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Causes Of A Hemorrhagic Stroke
There are two possible causes of a ruptured blood vessel in the brain. The most common cause is an aneurysm. An aneurysm occurs when a section of a blood vessel becomes enlarged from chronic and dangerously high blood pressure or when a blood vessel wall is weak, which is usually congenital. This ballooning leads to thinning of the vessel wall, and ultimately to a rupture.
A rarer cause of an ICH is an arteriovenous malformation . This occurs when arteries and veins are connected abnormally without capillaries between them. AVMs are congenital. This means theyre present at birth, but theyre not hereditary. Its unknown exactly why they occur in some people.
What To Expect When Your Loved One Develops Brain Bleed While Being Hospitalized For A Stroke
It is important to understand that brain bleed after a stroke is not always a disaster. If your loved one received timely treatment for a stroke and was doing better with improved symptoms, small brain bleed seen on a CT scan may not be significantly worse.
Any new brain bleed after a stroke requires close monitoring in the hospital. If your loved one was being treated on a regular floor of the hospital, you can expect to him or her to be moved to the ICU for closer monitoring. They will watch out for signs of increased pressure inside the brain. Worsening headaches, nausea, or vomiting may signal high pressure inside the brain, and could be cause for concern.
Large brain bleed after a stroke can be very difficult to treat and has a worse outcome. They can sometimes try to treat the bleeding by giving medications to reverse the clot-busting medications used in the treatment of the initial stroke. They can also transfuse platelets to see if that would help prevent any further bleeding. However, large brain bleed has a very poor outcome, and only a small percentage of people with large brain bleed after a stroke survive.
Some patients with brain bleed after a stroke may benefit from surgery. Patients who have moderate-sized bleeding along with increased pressure inside the brain might do better if that pressure can be surgically relieved. Neurosurgeons have several different surgical techniques they can use to try to achieve that goal. It only works in a few patients.
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How Is Hemorrhagic Stroke Diagnosed
Evaluation of hemorrhagic stroke usually begins in the emergency room. Stroke specialists will conduct a rapid physical examination and the care team will work to quickly confirm and locate the cause of the stroke through imaging tests. These can include:
All of these tests are painless and noninvasive, although some might require placement of an intravenous line to deliver agents needed for certain types of imaging. Since MRI requires a child to hold still inside a scanner, very young children may need sedation. In some cases, the physician may recommend blood tests to help identify any underlying disorders that might cause bleeding.
How The Size And Location Of Brain Bleed After A Stroke Makes A Difference In The Final Outcome
Not all brain bleed after strokes cause a worse outcome than the original stroke. In fact, small amounts of blood leaking out after a stroke may be a sign that blood is flowing again in that part of the brain, signaling a better outcome. Many small brain bleeds after strokes may go undetected, because patients may not feel any worse with brain bleed than how they felt with the initial stroke.
In general, if the bleeding occupies 30% or more of the area of the brain affected by the stroke, the outcome will likely be worse. The larger the bleeding, the worse the expected outcome can be.
The location of the brain bleed and whether it is pushing on the surrounding brain tissue also makes a significant difference in the outcome. When the bleeding is in a confined area, it generates higher pressure and pushes on a part of the brain not affected by the initial stroke. That can lead to worsening symptoms, as the previously normal part of the brain begins to deteriorate with pressure.
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What Is A Brain Bleed
To most people, a brain bleed simply means any bleed inside your head. However, a doctor and specifically doctors who treats brain bleeds would say that a brain bleed is too broad of a term. These doctors further describe brain bleeds by their exact location.
To better understand brain bleeds, its important to have a basic understanding of the different types. First, there are two main areas where bleeding can occur bleeding can occur either within the skull but outside of the brain tissue, or inside the brain tissue. These areas are further divided as follows:
Bleeding within the skull but outside of the brain tissue
The brain has three membranes layers that lay between the bony skull and the actual brain tissue. The purpose of the meninges is to cover and protect the brain. Bleeding can occur anywhere between these three membranes. The three membranes are called the dura mater, arachnoid, and pia mater.
- Epidural bleed : This bleed happens between the skull bone and the outermost membrane layer, the dura mater.
- Subdural bleed : This bleed happens between the dura mater and the arachnoid membrane.
- Subarachnoid bleed : This bleed happens between the arachnoid membrane and the pia mater.
Brain bleeds can occur within the meninges, which is the area inside the skull but outside the actual brain tissue.
Bleeding inside the brain tissue
Two types of brain bleeds can occur inside the brain tissue itself intracerebral hemorrhage and intraventicular hemorrhage.
What Are The Types Of Brain Bleeds
Bleeds can happen inside the tissue of your brain or outside it.
When they happen outside the brain tissue, they involve one or more of the protective layers that cover your brain:
Epidural bleed. This is when blood collects between your skull and the thick outer layer, called the dura mater. Without treatment, it can make your blood pressure rise, give you trouble breathing, cause brain damage, or lead to death.
An epidural bleed usually happens due to an injury that tears an underlying blood vessel.
Subdural bleed. This is when blood leaks between your dura mater and the thin layer beneath it, called the arachnoid mater. There are two main kinds of subdural bleeds: The âacuteâ type develops fast, and itâs linked to a death rate that ranges from about 37% to 90%. Itâs common for people who survive one to have permanent brain damage.
Acute subdural bleeds can happen after a hit to the head from a fall, car crash, sports accident, whiplash, or other type of trauma.
Chronic subdural bleeds form gradually and arenât as deadly — fast treatment can lead to a better recovery, too. Itâs usually caused by a less-serious head injury in someone whoâs elderly, on blood thinning meds, or has brain shrinkage due to dementia or an alcohol use disorder.
Subarachnoid bleed. This is when blood collects below the arachnoid mater and above the delicate inner layer beneath it, the pia mater. Without treatment, it can lead to permanent brain damage and death.
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What Causes Bleeding In The Brain
There are several risk factors and causes of brain hemorrhages. The most common include:
- Head trauma. Injury is the most common cause of bleeding in the brain for those younger than age 50.
- High blood pressure. This chronic condition can, over a long period of time, weaken blood vessel walls. Untreated high blood pressure is a major preventable cause of brain hemorrhages.
- Aneurysm. This is a weakening in a blood vessel wall that swells. It can burst and bleed into the brain, leading to a stroke.
- Blood vessel abnormalities. Weaknesses in the blood vessels in and around the brain may be present at birth and diagnosed only if symptoms develop.
- Amyloid angiopathy. This is an abnormality of the blood vessel walls that sometimes occurs with aging and high blood pressure. It may cause many small, unnoticed bleeds before causing a large one.
- Blood or bleeding disorders. Hemophilia and sickle cell anemia can both contribute to decreased levels of blood platelets and clotting. Blood thinners are also a risk factor.
- Liver disease. This condition is associated with increased bleeding in general.
- Brain tumors.
What Are Recurrent Strokes
Recurrent strokes occur in about 1 in 4 people who have had a stroke within 5 years after a first stroke. The risk is greatest right after a stroke and decreases over time. The likelihood of severe disability and death increases with each recurrent stroke. About 3% of people who have had a stroke have a second stroke within 30 days of their first stroke, and about one-third have a second stroke within 2 years.
How Long Can A Person Live After A Hemorrhagic Stroke
Recovery from a stroke can be a long process, and approximately people who survive a stroke have another within 5 years.
Fortunately, researchers estimate that around 1239% of those who survive an intracerebral hemorrhage are able to achieve long-term functional independence.
Identifying and treating the underlying causes of a stroke may help improve outcomes and reduce the risk of recurrence.
Bleeding Within The Brain
Intracerebral haemorrhage is where blood leaks out of a blood vessel into the brain tissue, sometimes deep inside the brain. ICH is the most common type of haemorrhagic stroke, and around two thirds of all haemorrhagic strokes are ICH.
Main causes of ICH
Cerebral small vessel disease
Cerebral small vessel disease means having damage to very small blood vessels in your brain. This can lead to blood leaking into the brain tissue, often deep inside the brain. There are two main types:
- Small vessel disease due to high blood pressure.
High blood pressure is a main cause of small vessel disease in the brain. Over a long period, high blood pressure damages the blood vessels inside your brain, making them stiffen, and causing blockages.
Small areas of damage develop, which look like tiny scars on a brain scan. These damaged areas reduce the blood flow to your brain cells. This can affect your thinking ability and mood, and its linked to cognitive decline and dementia. It also makes a haemorrhagic stroke more likely to happen.
- Cerebral amyloid angiopathy .
This is a common type of small vessel disease where a protein called amyloid beta builds up inside the small blood vessels near the surface of the brain. This damages the blood vessels, making them more likely to bleed. This can cause a haemorrhagic stroke, and can also lead to microbleeds which dont always have obvious symptoms.
Abnormal blood vessels in the brain
- Arteriovenous malformation .
What Is A Hemorrhagic Stroke
Doctors may also use the term intracranial hemorrhage when talking about hemorrhagic stroke.
The bleeding in the brain puts pressure on surrounding brain cells and can cause areas of the brain to be deprived of blood. This leads to brain tissue damage, which can lead to neurologic symptoms and be life threatening.
This article discusses why hemorrhagic stroke happens, how to recognize it, and what treatments are available.
A hemorrhagic stroke is caused by bleeding in the brain. This can happen when a blood vessel in the brain bursts or when brain tissue starts to bleed. The damage from a hemorrhagic stroke can result from pressure caused by bleeding, edema, or a lack of blood supply.
Brain tissue can bleed after an ischemic stroke, which is a stroke caused by a blocked blood supply. This damages brain tissue, making it frail and prone to bleeding.
There is an especially high risk of a hemorrhagic stroke after a large ischemic stroke with extensive brain damage and tissue swelling. This is called a . It can happen anywhere from a few days to 2 weeks after an ischemic stroke.
Other common causes of hemorrhagic stroke brain tumors, tumors that metastasize to the brain, and severe infections in the brain.
Treatment For Hemorrhagic Strokes
Treatment of a hemorrhagic stroke depends on the cause of the bleeding. The first step in treatment is to quickly determine the cause and reduce the pressure caused by the bleeding.
Prompt medical treatment can minimize damage to the brain. While immediate medical attention is critical, some patients experiencing hemorrhagic stroke have as long as 48 to 72 hours when they can still benefit from treatment.
UT Southwestern offers endovascular procedures and surgical treatments to prevent or treat the causes of hemorrhagic stroke.
Endovascular treatment involves the use of a catheter that enters the body through the groin to access the brain arteriovenous malformation . Our neurointerventional surgeons thread a tiny platinum coil through the catheter and deploy it into the aneurysm, blocking blood flow into the AVM and preventing rupture or re-rupture.
We might recommend a surgical procedure to prevent or stop bleeding or reduce pressure inside the skull. If an aneurysm is the potential cause of the stroke, we can clip it at the base to prevent bleeding before a stroke or to prevent re-bleeding. The availability of both surgical and endovascular options is crucial to give patients the best chance at a successful long-term outcome.
