Hemorrhagic Stroke

용어의 혼란 :

중풍 혹은 뇌졸증을 영어로는 STROKE 라 한다. CVA = CerebroVascular Accident (cerebral accident) 가 중풍이다.

뇌경색 cerebral infarction 과 뇌일혈cerebral hemorrhage을 포함한다. 

그런데 보통 stroke 라고 하면 뇌경색 (cerebrovascular infarction)을 뜻하고 뇌일혈은 Hemorrhagic Stroke 이라 한다.

Hemorrhagic Stroke

Hemorrhagic strokes include bleeding within the brain (intracerebral hemorrhage) and bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid hemorrhage). There are two main types of hemorrhagic strokes: intracerebral hemorrhage and subarachnoid hemorrhage. Other disorders that involve bleeding inside the skull include epidural hematomas (see Head Injuries: Epidural Hematomas) and subdural hematomas (see see Head Injuries: Subdural Hematomas), which are usually caused by a head injury. These disorders cause different symptoms and are not considered strokes. Bursts and Breaks: Causes of Hemorrhagic Stroke When blood vessels of the brain are weak, abnormal, or under unusual pressure, a hemorrhagic stroke can occur. In hemorrhagic strokes, bleeding may occur within the brain, as an intracerebral hemorrhage. Or bleeding may occur between the inner and middle layer of tissue covering the brain (in the subarachnoid space), as a subarachnoid hemorrhage. Intracerebral Hemorrhage An intracerebral hemorrhage is bleeding within the brain. Intracerebral hemorrhage usually results from chronic high blood pressure. The first symptom is often a severe headache. Diagnosis is based on symptoms and results of a physical examination and imaging tests. Treatment may include vitamin K, transfusions, and, rarely, surgery to remove the accumulated blood. Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher percentage of deaths due to stroke. Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage. Causes Intracerebral hemorrhage most often results when chronic high blood pressure weakens a small artery, causing it to burst. Using cocaine or amphetamines can cause temporary but very high blood pressure and hemorrhage. In some older people, an abnormal protein called amyloid accumulates in arteries of the brain. This accumulation (called amyloid angiopathy) weakens the arteries and can cause hemorrhage. Less common causes include blood vessel abnormalities present at birth, injuries, tumors, inflammation of blood vessels (vasculitis), bleeding disorders, and use of anticoagulants in doses that are too high. Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage. Symptoms An intracerebral hemorrhage begins abruptly. In about half of the people, it begins with a severe headache, often during activity. However, in older people, the headache may be mild or absent. Symptoms suggesting brain dysfunction develop and steadily worsen as the hemorrhage expands. Some symptoms, such as weakness, paralysis, loss of sensation, and numbness, often affect only one side of the body. People may be unable to speak or become confused. Vision may be impaired or lost. The eyes may point in different directions or become paralyzed. The pupils may become abnormally large or small. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes. Diagnosis Doctors can often diagnose intracerebral hemorrhages on the basis of symptoms and results of a physical examination. However, computed tomography (CT) or magnetic resonance imaging (MRI) is also done. Both tests can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The tests can also show how much brain tissue has been damaged and whether pressure is increased in other areas of the brain. The blood sugar level is measured because a low blood sugar level can cause symptoms similar to those of stroke. Prognosis Intracerebral hemorrhage is more likely to be fatal than ischemic stroke. The hemorrhage is usually large and catastrophic, especially in people who have chronic high blood pressure. More than half of the people who have a large hemorrhage die within a few days. Those who survive usually recover consciousness and some brain function over time. However, most do not recover all lost brain function. Treatment Treatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin and warfarinSome Trade Names COUMADIN ), thrombolytic drugs, and antiplatelet drugs (such as aspirinSome Trade Names BAYER ) are not given because they make bleeding worse. If people who are taking an anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood clot such as Vitamin K, usually given intravenously Transfusions of platelets Transfusions of blood that has had blood cells and platelets removed (fresh frozen plasma) Intravenous administration of a synthetic product similar to the proteins in blood that help blood to clot (clotting factors) Surgery to remove the accumulated blood and relieve pressure within the skull, even if it may be life-saving, is rarely done because the operation itself can damage the brain. Also, removing the accumulated blood can trigger more bleeding, further damaging the brain and leading to severe disability. However, this operation may be effective for hemorrhage in the pituitary gland or in the cerebellum. In such cases, a good recovery is possible. Subarachnoid Hemorrhage A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges). The most common cause is rupture of a bulge (aneurysm) in an artery. Usually, rupture of an artery causes a sudden, severe headache, often followed by a brief loss of consciousness. Computed tomography, sometimes a spinal tap, and angiography are done to confirm the diagnosis. Drugs are used to relieve the headache and to control blood pressure, and surgery is done to stop the bleeding. A subarachnoid hemorrhage is a life-threatening disorder that can rapidly result in serious, permanent disabilities. It is the only type of stroke more common among women than among men. Causes Subarachnoid hemorrhage usually results from head injuries. However, hemorrhage due to a head injury causes different symptoms and is not considered a stroke. Subarachnoid hemorrhage is considered a stroke only when it occurs spontaneously—that is, when the hemorrhage does not result from external forces, such as an accident or a fall. A spontaneous hemorrhage usually results from the sudden rupture of an aneurysm in a cerebral artery. Aneurysms are bulges in a weakened area of an artery's wall. Aneurysms typically occur where an artery branches. Aneurysms may be present at birth (congenital), or they may develop later, after years of high blood pressure weaken the walls of arteries. Most subarachnoid hemorrhages result from congenital aneurysms. Less commonly, subarachnoid hemorrhage results from rupture of an abnormal connection between arteries and veins (arteriovenous malformation) in or around the brain. An arteriovenous malformation may be present at birth, but it is usually identified only if symptoms develop. Rarely, a blood clot forms on an infected heart valve, travels (becoming an embolus) to an artery that supplies the brain, and causes the artery to become inflamed. The artery may then weaken and rupture. Did You Know... Almost half of people with a subarachnoid hemorrhage die before reaching the hospital. Symptoms Before rupturing, an aneurysm usually causes no symptoms unless it presses on a nerve or leaks small amounts of blood, usually before a large rupture (which causes headache). Then it produces warning signs, such as the following: Headache, which may be unusually sudden and severe (sometimes called a thunderclap headache) Facial or eye pain Double vision Loss of peripheral vision The warning signs can occur minutes to weeks before the rupture. People should report any unusual headaches to a doctor immediately. A rupture usually causes a sudden, severe headache that peaks within seconds. It is often followed by a brief loss of consciousness. Almost half of affected people die before reaching a hospital. Some people remain in a coma or unconscious. Others wake up, feeling confused and sleepy. They may also feel restless. Within hours or even minutes, people may again become sleepy and confused. They may become unresponsive and difficult to arouse. Within 24 hours, blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), causing a stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain. Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures. About 25% of people have symptoms that indicate damage to a specific part of the brain, such as the following: Weakness or paralysis on one side of the body (most common) Loss of sensation on one side of the body Difficulty understanding and using language (aphasia—see Brain Dysfunction: Aphasia) Severe impairments may develop and become permanent within minutes or hours. Fever is common during the first 5 to 10 days. A subarachnoid hemorrhage can lead to several other serious problems: Hydrocephalus: Within 24 hours, the blood from a subarachnoid hemorrhage may clot. The clotted blood may prevent the fluid surrounding the brain (cerebrospinal fluid) from draining as it normally does. As a result, blood accumulates within the brain, increasing pressure within the skull. Hydrocephalus may contribute to symptoms such as headaches, sleepiness, confusion, nausea, and vomiting and may increase the risk of coma and death. Vasospasm: About 3 to 10 days after the hemorrhage, arteries in the brain may contract (spasm), limiting blood flow to the brain. Then, brain tissues may not get enough oxygen and may die, as in ischemic stroke. Vasospasm may cause symptoms similar to those of ischemic stroke, such as weakness or loss of sensation on one side of the body, difficulty using or understanding language, vertigo, and impaired coordination. A second rupture: Sometimes a second rupture occurs, usually within a week. Diagnosis If people have a sudden, severe headache that peaks within seconds or that is accompanied by any symptoms suggesting a stroke, they should go immediately to the hospital. Computed tomography (CT) is done to check for bleeding. A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that pressure within the skull is increased. Cerebral angiography (see Brain Dysfunction: Aphasia) is done as soon as possible to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding. Magnetic resonance angiography or CT angiography may be used instead. Prognosis About 35% of people die when they have a subarachnoid hemorrhage due to an aneurysm because it results in extensive brain damage. Another 15% die within a few weeks because of bleeding from a second rupture. People who survive for 6 months but who do not have surgery for the aneurysm have a 3% chance of another rupture each year. The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography because the defect has already sealed itself off. In such cases, the outlook is very good. Some people recover most or all mental and physical function after a subarachnoid hemorrhage. However, many people continue to have symptoms such as weakness, paralysis, or loss of sensation on one side of the body or aphasia. Treatment People who may have had a subarachnoid hemorrhage are hospitalized immediately. Bed rest with no exertion is essential. Analgesics such as opioids (but not aspirinSome Trade Names BAYER or other nonsteroidal anti-inflammatory drugs, which can worsen the bleeding) are given to control the severe headaches. Stool softeners are given to prevent straining during bowel movements. Nimodipine, a calcium channel blocker, is usually given by mouth to prevent vasospasm and subsequent ischemic stroke. Doctors take measures (such as giving drugs and adjusting the amount of intravenous fluid given) to keep blood pressure at levels low enough to avoid further hemorrhage and high enough to maintain blood flow to the damaged parts of the brain. Occasionally, a piece of plastic tubing (shunt) may be placed in the brain to drain cerebrospinal fluid away from the brain. This procedure relieves pressure and prevents hydrocephalus. For people who have an aneurysm, a surgical procedure is done to isolate, block off, or support the walls of the weak artery and thus reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people who are in a stupor or coma. The best time for surgery is controversial and must be decided based on the person's situation. Most neurosurgeons recommend operating within 24 hours of the start of symptoms, before hydrocephalus and vasospasm develop. If surgery cannot be done this quickly, the procedure may be delayed 10 days to reduce the risks of surgery, but then bleeding is more likely to recur because the waiting period is longer. A commonly used procedure, called neuroendovascular surgery, involves inserting coiled wires into the aneurysm. The coils are placed using a catheter that is inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened. By slowing blood flow through the aneurysm, the coils promote clot formation, which seals off the aneurysm and prevents it from rupturing. Neuroendovascular surgery can often be done at the same time as cerebral angiography, when the aneurysm is diagnosed. Less commonly, a metal clip is placed across the aneurysm. This procedure prevents blood from entering the aneurysm and eliminates the risk of rupture. The clip remains in place permanently. Most clips that were placed 15 to 20 years ago are affected by the magnetic forces and can be displaced during magnetic resonance imaging (MRI). People who have these clips should inform their doctor if MRI is being considered. Newer clips are not affected by the magnetic forces. Spotlight on Aging After a stroke, older people are more likely to have problems, such as pressure sores, pneumonia, permanently shortened muscles (contractures) that limit movement, and depression. Older people are also more likely to already have disorders that limit treatment of stroke. For example, they may have very high blood pressure or gastrointestinal bleeding that prevents them from taking anticoagulants to reduce the risk of blood clots. Some treatments, such as endarterectomy, are more likely to cause complications in older people. Nonetheless, treatment decisions should be based on the person's health rather than on age itself. Some disorders common among older people can interfere with their recovery after a stroke, as in the following: People with dementia may not understand what is required of them for rehabilitation. People with heart failure or another heart disorder may risk having another stroke or a heart attack triggered by exertion during rehabilitation exercises. A good recovery is more likely when older people have a family member or caregiver to help, a living situation that facilitates independence (for example, a first-floor residence and nearby shops), and financial resources to pay for rehabilitation. Because recovery after stroke depends on so many medical, social, financial, and lifestyle factors, rehabilitation and care for older people should be individually designed and managed by a team of health care practitioners (including nurses, psychologists, and social workers as well as a doctor or therapist). Team members can also provide information about resources and strategies to help people who have had a stroke and their caregivers with daily living. Last full review/revision November 2007 by Elias A. Giraldo, MD, MS