Stroke

Treatment of Hemorrhagic Stroke at Mayo Clinic

Hemorrhagic stroke is caused by a blood vessel in the brain that breaks and bleeds into the brain. About 20 percent of strokes are hemorrhagic. Cells nourished by the ruptured artery no longer receive oxygen and nutrients and begin to die. Also, accumulated blood from the ruptured artery clots, pushing on normal brain tissue and disrupting brain function.

Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke. Hemorrhagic stroke has two main types. Each is named according to the part of the brain affected by the bleeding:

• subarachnoid hemorrhage refers to bleeding that occurs in the space between the surface of the brain and the skull. A common cause of subarachnoid hemorrhagic stroke is a burst aneurysm (an abnormal "bulging" of a blood vessel in the brain) or the rupture of an arteriovenous malformation, a congenitally malformed tangle of thin-walled blood vessels.
• intracerebral hemorrhage refers to bleeding that occurs within the brain tissue. Many intracerebral hemorrhages are caused by a change in the arteries due to long-standing hypertension. Many other potential causes may be defined by additional testing.

Treatment Options

In a hemorrhagic stroke, treatment is based on the underlying cause of the hemorrhage and the extent of damage to the brain.

Depending on the severity, treatment includes lifesaving measures, relief of symptoms and repair of the cause of the bleeding.

Immediate treatment for hemorrhagic strokes is best administered in an intensive care unit, where medical personnel can immediately detect any complications. Sometimes persons experiencing a hemorrhagic stroke develop irregular breathing patterns or stop breathing. Medical intervention may be needed to protect the airway and avoid choking or inhaling secretions into the lungs if a patient is unconscious or semiconscious.

In addition to basic life support, treatment includes:

Medications

If high blood pressure causes a hemorrhagic stroke, antihypertensive drugs are administered to bring blood pressure down. In addition, brain bleeding may cause swelling of surrounding brain tissue, and this may require therapy with drugs called hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions).

If the hemorrhage resulted from the use of anticoagulants, such as Coumadin or heparin, these medications are discontinued immediately. Medications may be given to reverse the effects of these anticoagulants to reduce bleeding.

In addition, pain relievers and antianxiety medications may relieve the headache that often accompanies hemorrhagic stroke. Medications may be needed to prevent or treat seizures.

Surgery and other procedures

Surgery or another procedure may be needed to save a patient's life or to improve the chances of meaningful recovery. The type of surgery depends upon the cause of the bleeding, and is usually divided into three categories:

Aneurysm Treatments

• Aneurysm clipping
  

  Aneurysm clipping involves opening the skull to expose the aneurysm and placing a clip to prevent future leaking of blood from the affected artery. The goal of surgery for subarachnoid bleeding is to reduce the chances of a second bleed from an aneurysm, which is often fatal.

• Endovascular treatment of aneurysms
  

  In this procedure, a radiologist passes a catheter (thin tube) through the artery to the opening into an aneurysm. Detachable platinum coils are then deposited in the aneurysm to fill it up and prevent blood from entering, eliminating the possibility of hemorrhage. Other endovascular treatments for aneurysms are being evaluated.

Read more about aneurysms.

AVM Treatment

• Surgical arteriovenous malformation removal
  

  It is not always possible to remove an arteriovenous malformation (AVM) if it is too large or located deep within the brain. Surgical removal of a smaller AVM from a more accessible portion of the brain can eliminate the risk of AVM rupture. Stereotactic microsurgery, using sophisticated computer technology, cameras and delicate instruments may be used to remove arteriovenous malformations.

• Stereotactic Radiosurgery
  

  Stereotactic radiosurgery may be used to obliterate AVMs. This procedure focuses a beam of radiation on the AVM, causing it to clot and eventually disappear.

• Endovascular treatment (coil embolization) of AVMs
  

  This procedure is similar to the treatment for aneurysms. A catheter is inserted into a leg artery and threaded through the body to the brain arteries. The catheter is positioned in one of the feeding arteries to the AVM, and coils, small particles or a gluelike substance is injected to block the vessel and reduce the blood flow into the AVM. In some large AVMs that appear "inoperable," embolization makes the AVM smaller, allowing it to be treated with surgery or radiosurgery. In rare cases, endovascular embolization may obliterate or cure the AVM, eliminating the need for other therapy.

Read more about arteriovenous malformations (AVM).

General Hemorrhage Treatments

• Removal of hematoma
  

  Removal of a hematoma (a collection of blood, usually clotted, resulting from a break in the wall of a blood vessel) may be needed, especially when bleeding occurs in the back of the brain. Some physicians are investigating whether the injection of a clot busting drug inside the hematoma can help with the removal of brain hemorrhages through needles or catheters, therefore allowing less invasive surgery.

• Ventriculostomy
  

  A procedure called ventriculostomy may be performed if fluid accumulates due to bleeding in the brain and needs to be drained.