What Is A Hemorrhagic Stroke?

A hemorrhagic stroke occurs when a blood vessel inside the brain bursts. The bleeding damages the surrounding brain tissue. The brain cells are much more gentle and sensitive than any other cells in the human body. The bleeding increases the pressure applied to the brain cells that surround the bleeding and this is what causes the damage.

The most common cause of hemorrhagic stroke is high blood pressure. Another cause is an aneurysm. It causes the blood vessel wall to become thinner and bust at some point. Stroke can also be caused by the accumulation of a protein called amyloid within the artery walls, particularly in the elderly. This makes the arteries more prone to bleeding.

Hemorrhagic strokes form nearly 20% of all stroke cases. It may occur in all ages and the average risk age is lower than the ischemic stroke risk age.

The symptoms of the hemorrhagic stroke include weakness or inability to move some part of the body, numbness or loss of sensation, decrease or lost vision, speech difficulties, disorientation and inability to recognize familiar faces, sudden headache, dizziness, etc.

The hemorrhagic stroke can be treated through surgery or with medication only. Depending on the severity, treatment includes lifesaving measures, relief of symptoms and repair of the cause of the bleeding. Surgery can help to reduce the brain damage caused by the stroke as well as quicken the recovery. Regardless of the treatment chosen a person who has suffered a hemorrhagic stroke needs a serious long term treatment. Most of the patients need physical therapy, others need behavior modification or family counseling.

There are different types of hemorrhagic stroke - subarachnoid hemorrhage and intracerebral hemorrhage. The subarachnoid hemorrhage occurs when a blood vessel in the area between the brain and the skull starts bleeding. The intracerebral hemorrhage occurs when a blood vessel deep inside the brain starts bleeding. Both types may be caused by structural problems with the arteries such as an aneurysm or Arteriovenous Malformation. The aneurysm is a week area in the blood vessel wall that fills with blood and bulges. High blood pressure or an injury may cause the bulge to rupture and start bleeding. Arteriovenous Malformation is a malformation of the brain's blood vessels. This kind of malformation is usually present since birth and develops slowly with time. It characterizes weak blood vessels that increase the risk of a hemorrhagic stroke.

AVM Surgery

Arteriovenous malformations are masses of abnormal blood vessels that grow in the brain. They consist of a blood vessel "nidus" (nest) through which arteries connect directly to veins, instead of through the elaborate collection of very small vessels called capillaries. Some people are born with the nidus, but as the years go by, it tends to enlarge as the great pressure of the arterial vessels can not be handled by the veins that drain out of it. This causes a large collection of worm-like vessels to develop (malformed) into a mass capable of bleeding at some future time. These malformations are most likely to bleed between the ages of 10 - 55; after 55, the chances of bleeding diminishes rapidly. Before 55, the likelihood of hemorrhaging is between 3 and 4% per year (with a death incidence of about 1%). Once an AVM patient has hemorrhaged, the risk of having another one might approach 20% during the first year, and gradually lessen to about 3 - 4% over the next few years.

AVM s can occur in any area of the brain and can be either small or large. When they hemorrhage, they usually do so with a limited amount of blood, unlike the hypertensive hemorrhages of other stroke patients. The loss of neurologic function depends on both the location of the AVM and the amount of bleeding. Many patients have very small hemorrhages, often multiple. They may display convulsions before even knowing about the presence of an AVM. Some patients suffer from headaches, often unrelated to the AVM which is usually found with a CT scan or brain MRI. In rare instances, children are born with large AVM's and are found to have heart failure because the malformation makes the heart work beyond its capacity.

These lesions are surrounded by a very discrete layer of abnormal, nonfunctioning brain tissue, thus allowing their removal with relative safety to the surrounding brain. This factor is of the utmost importance to the brain surgeon, who can take advantage of this natural separation between normal brain tissue and the abnormal vascular malformation.

TREATMENT OPTIONS

Radiation

If there is a very small AVM, and it is deep-seated in the brain, the patient is fortunate. It is possible to give focused beam radiation to the malformation and avoid surgery. Within two years the malformation will most likely disappear.

Embolization

Larger malformations may be made more surgically manageable with a technique called embolization. With this procedure, an angiogram becomes a therapeutic tool. The interventional angiographer is capable of filling the malformation with agents which help decrease the blood supply to the malformation (coils, glues, plastic spheres, balloons, etc). This makes surgery easier in some cases. The technique has been used as the primary treatment as well and has apparently been successful in some cases.

Surgery

Perhaps surgery is still the best way to go if the decision has been made to do something to eliminate the AVM for good. Surgery cures these lesions by totally removing them, thus disallowing them from ever recurring again. The author's personal bias (quite strongly held) is that most AVMs are best cared for with surgical removal. Even with patients who have large and complex AVMs, surgery provides the cure when the malformation is completely removed.

Benefits of surgery 

A team of specialists in all the disciplines are present to make an accurate diagnosis and arrive at the best course of action to eradicate the disease. Since the success of your surgery is largely dependent on your choice of surgeon, the objective of the doctor is to provide appropriate pre and post-surgery care.