Patient education: Hemorrhagic stroke treatment (Beyond the Basics)

STROKE OVERVIEW — In the United States, approximately 750,000 strokes occur each year. During a stroke, one or more areas of the brain can be damaged. Depending upon the area affected, a person may lose the ability to move one side of the body, the ability to speak, or a number of other functions. The damage may be temporary or permanent, and the function may be partially or completely lost. A person's long-term outcome depends upon how much brain is damaged, how quickly treatment begins, and a number of other factors.

Strokes are a leading cause of long-lasting injury, disability, and death. Early treatment and preventive measures can reduce the brain damage that occurs as a result of a stroke. The treatment of a stroke depends upon the type of stroke (eg, ischemic or hemorrhagic), the time since the first stroke symptoms occurred, and the patient's underlying medical problems. General information about the treatment of hemorrhagic strokes is provided here.

A separate topic review is available that discusses the signs, symptoms, and diagnosis of ischemic and hemorrhagic strokes (see "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)"). A topic is also available that discusses the treatment of ischemic stroke. (See "Patient education: Ischemic stroke treatment (Beyond the Basics)".)

WHAT IS A HEMORRHAGIC STROKE? — Hemorrhage is the medical term for bleeding. Hemorrhagic stroke occurs when blood vessels in the brain leak or rupture, causing bleeding in or around the brain. About 20 percent of strokes are hemorrhagic strokes. Damage can occur quickly due to the pressure of increasing amounts of blood or because of the blood itself. Blood is irritating to the brain tissue, causing it to swell.

Bleeding around the brain is referred to as subarachnoid hemorrhage (SAH) and is often caused by rupture of an abnormal blood vessel (aneurysm) on the surface of the brain. Bleeding into the brain is called intracerebral hemorrhage (ICH) and is often caused by high blood pressure.

STROKE TREATMENT

Medical treatment for all patients — The treatment of a hemorrhagic stroke depends upon the cause of the bleeding (eg, high blood pressure, use of anticoagulant medications, head trauma, blood vessel malformation). Most patients are monitored closely in an intensive care unit during and after a hemorrhagic stroke. The initial care of a person with hemorrhagic stroke includes several components:

●Determining the cause of the bleeding.

●Controlling the blood pressure.

●Stopping any medication that could increase bleeding (eg, warfarin or another blood thinner, aspirin). If the patient has been taking a blood thinner, specific treatments or transfusions of blood clotting factors may be given to stop ongoing bleeding.

●Measuring and controlling the pressure within the brain and within the skull.

Pressure within the brain can be measured by placing a device, known as a ventriculostomy tube, through the skull into an area of the brain called the ventricle. If the pressure is elevated, a small amount of cerebrospinal fluid can be removed from the ventricle. A ventriculostomy can also be used to drain blood that has collected in the brain as a result of the stroke. The procedure can be done at the patient's bedside or in an operating room.

Indications for surgical treatment — A surgical procedure may be recommended to prevent or stop bleeding or reduce the pressure inside the skull. Depending upon the stroke severity and the patient's condition, surgery may be done within the first 48 to 72 hours after the hemorrhage or it may be delayed until one to two weeks later to allow the patient's condition to stabilize.

Ruptured aneurysm — An aneurysm is a blood vessel that has a weak area that balloons out. If the area ruptures and bleeds, a hemorrhagic stroke can occur.

A clamp can be placed at the base of the aneurysm to prevent bleeding before a stroke or to prevent rebleeding. This surgery requires removing a piece of the skull and locating the aneurysm within the brain tissue. This procedure is done after the patient is given general anesthesia and often requires several hours to complete. The piece of skull is replaced at the end of the surgery.

Coil embolization is an interventional procedure that is less invasive than clipping and can be done while the patient is sedated or put to sleep with medications. It involves inserting a flexible tube (catheter) into an artery in the groin. The catheter is guided along blood vessels in the body into the vessel in the brain where the aneurysm is located. A tiny coil is advanced into the weakened area (aneurysm), filling the area with the coil. A blood clot forms within the coil, blocking blood flow into the aneurysm and preventing it from rupturing again. Other materials may also be injected to treat an aneurysm or arteriovenous malformation (AVM).

A newer treatment for aneurysms uses stents called flow diverters that decrease blood flow to the aneurysm.

Arteriovenous malformation — Some AVMs have a significant risk of further bleeding. The decision to treat an AVM depends on several factors; the main factors are the patient age, AVM location and size, and abnormalities of the veins that drain the malformation and whether or not the AVM has previously bled. Treatment could include surgery, radiosurgery (use of radiation to shrink blood vessels), or embolization techniques.

Brain herniation — When a patient's life appears to be threatened because of the pressure effects of a blood clot or swelling in the brain, the physician may consider a procedure to open the skull and/or remove the blood. Considerations include the location and size of the hemorrhage, the patient's age and medical condition, and the likelihood of making a recovery from the stroke.

STROKE COMPLICATIONS — A number of problems can develop in people who have had a stroke. These complications are significant because approximately half of deaths after stroke are due to medical complications. In the days and weeks after a stroke, clinicians, the patient, family members, and other caregivers can work to decrease the risk of some of these complications. Common complications include the following:

●Blood clots

●Difficulty eating and drinking, which increases the risk of pneumonia and malnutrition

●Urinary tract infection

●Bleeding in the digestive system

●Heart attack or heart failure

●Bed sores

●Falls

Blood clots — People who have strokes are at increased risk of developing blood clots as they recover. A deep vein thrombosis (DVT) is a blood clot that develops in the deep veins of the leg. If the clot breaks off, it can travel to the lung, where it is called a pulmonary embolus (PE). A PE can cause serious and potentially fatal changes in blood flow throughout the body. These blood clots occur most often between the second and seventh day after the stroke.

The risk of pulmonary embolism is especially high in stroke patients who have difficulty with moving or walking around during the recovery period. Difficulty walking may be related to paralysis caused by the stroke or to other medical conditions. Lack of movement increases the risk of a deep vein thrombosis. To decrease the risk of blood clots, the patient is encouraged to get up and move around frequently as soon as they are able to do so. A physical therapist is often available to help, especially if the patient has weakness in the legs as a result of the stroke.

Special stockings are put around the patient's calves to provide intermittent pneumatic compression to prevent a blood clot from forming in a leg vein that might travel to the lung. Once bleeding inside the head has stopped, low doses of a blood thinner (heparin or low molecular weight heparin) may be added to prevent a blood clot in a deep vein of the leg or a blood clot that travels to the lung. However, the benefit of heparin for preventing a pulmonary embolus must be balanced with the increased risk of bleeding related to heparin. (See "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)".)

Difficulty swallowing — The act of swallowing requires coordination of the nerves and muscles of the tongue, mouth, and throat. The brain damage that occurs as a result of a stroke can cause muscle weakness and difficulty swallowing. Dysphagia is the medical term for difficulty swallowing.

Dysphagia is concerning because it increases the risk of inhaling saliva or food into the lungs, which can cause a type of pneumonia known as aspiration pneumonia. Patients with stroke-related pneumonia have a higher risk of death and a poorer long-term outcome when compared with patients without pneumonia. However, in people who have weakness of one side of the body, dysphagia is often temporary because both sides of the brain and body control swallowing.

To determine if a patient is at risk for inhaling food or drinks into the lungs, a simple water swallow test may be done. If the patient has difficulty swallowing water, the clinician may recommend that the patient not eat or drink anything temporarily. In the meantime, medication and nutrition can be given into a vein. Specific exercises and training programs can help to retrain a person how to swallow despite muscle or nerve damage. An additive to thicken liquids may be recommended.

Inadequate nutrition — After a stroke, some patients have difficulty consuming an adequate number of calories. In addition, some patients are underweight or malnourished before their stroke. These problems can interfere with a person's ability to recover from stroke, potentially increasing the risk of long-term disability.

For these reasons, a patient's nutritional status should be evaluated before discharge from the hospital. This includes a review of the patient's past and current body weight, a basic history of the patient's eating habits, blood testing, and a physical examination that focuses on the condition of the eyes, hair, skin, mouth, and muscles.

If a person is not able to consume an adequate number of calories, a feeding tube may be placed through the nose and into the stomach (called a nasogastric tube). If the feeding tube will be needed for more than two to three weeks, a tube can be inserted through the abdomen into the stomach (called a percutaneous endoscopic gastrostomy [PEG] tube). The PEG tube may be removed if the person regains the ability to eat normally.

Urinary tract infection — After a stroke, some patients have difficulty getting out of bed to empty their bladder. Others have difficulty with urinary leakage or are not able to empty their bladder completely because of muscle weakness. For these reasons, a catheter is often placed inside the bladder, especially during the first few days to weeks after a stroke. However, there is an increased risk of urinary tract infections related to the use of a catheter.

Urinary tract infections are a common complication after stroke, occurring in about 11 percent of patients during the first three months after stroke.

There are a number of strategies that can decrease the risk of urinary tract infections in patients who require a catheter. A few of these strategies are listed below:

●Use a catheter only when necessary.

●Remove the catheter as soon as possible.

●It is not necessary to change the catheter to prevent infections. The catheter should only be changed if it begins to crack or deteriorate or if the patient has a urinary tract infection.

●For males, there is a lower risk of infections with a condom-type catheter.

●There are not good data to support using antibiotics to prevent infection during catheter use. Antibiotics are recommended to treat a urinary tract infection if it develops.

Seizures — The risk of seizures in patients who have had a hemorrhagic stroke is about 15 percent. Patients who have a seizure are treated with antiseizure medications to prevent the seizures from recurring. Some physicians may choose to start seizure medication as a preventive measure even if a seizure has not occurred.

Heart problems — Heart problems, such as an irregular heart rhythm (called an arrhythmia) or heart attack (called a myocardial infarction) may occur following stroke. It is important to determine whether the heart problems are caused by the stroke, unrelated to it, or the cause of the stroke. Tests commonly performed to screen for these problems include an electrocardiogram (ECG), blood testing, and continuous monitoring of the heart rhythm (called telemetry). In some cases, the person may not be able to tell the clinician that they feel chest pain. The ECG will help the clinician to diagnose and treat heart problems as quickly as possible.

Bed sores — Bed sores are areas of skin and underlying tissue that are injured when compressed between a bone (eg, tail bone) and an external surface (eg, a mattress) for a prolonged period of time. Other names for bed sores are pressure sores and decubitus ulcers.

The consequences of this type of skin injury range from mild skin redness to deep ulcers extending down to the bone. The ulcer can be uncomfortable and increases the risk of infection for the patient and also potentially increases the healthcare costs and hospital stay.

Bed sores are common in people with a limited ability to move without assistance and may be preventable by moving or turning (or being moved by a family member or other caregiver) at least every two hours. It is recommended that:

●Patients should be placed at a 30-degree angle when lying on their side to avoid direct pressure over the hip bone (greater trochanter).

●Pillows or foam wedges may need to be placed between the ankles and knees to avoid pressure at these sites.

●The heels require particular attention; pillows may be placed under the lower legs to elevate the heels, or special heel protectors can be used.

●Elevation of the head of the bed should be limited.

Chair-bound patients may generate considerable pressures over the sit bones (ischial tuberosities); they should probably be repositioned at least every hour.

Falls — After a stroke, many people have difficulty walking due to muscle weakness, paralysis, or lack of coordination. When a person becomes less active or unable to walk, they are at increased risk of bone thinning (osteoporosis), blood clots, and worsened muscle weakness. These risks greatly increase the chance of breaking a bone after a fall. Falls are one of the most common complications of stroke, occurring in up to 25 percent of patients.

To reduce the risk of falls, several interventions may be helpful:

●Muscle strengthening and balance retraining exercises – This may include exercise or rehabilitation programs tailored to an individual's needs and abilities. Group classes, such as tai chi, may be helpful for patients who are able to walk without assistance.

●Evaluation of fall risk – An evaluation may be recommended to determine if a person is at risk for falling. If there is a risk of falling, treatments (eg, a walker, balance training) may be recommended to decrease the risk.

●Home hazards – Home hazards such as poor lighting or loose rugs can increase the risk of falling. The following tips can reduce this risk:

•Remove loose rugs, electrical cords, or other items that could lead to tripping, slipping, and falling.

•Ensure that there is adequate lighting in all areas inside and around the home (including stairwells and entrance ways).

•Avoid walking on ice, wet or polished floors, or other potentially slippery surfaces, and avoid walking in unfamiliar areas outside.

•Ensure that the person has properly fitted, nonslip footwear.

STROKE OUTCOME — A patient's healthcare team can often provide guidance to family members regarding the patient's risk of long-term disability or death. However, it may difficult to know exactly what to expect, and, in most cases, it is necessary to watch and wait.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Brain aneurysm (The Basics)
Patient education: Intracerebral hemorrhage (The Basics)
Patient education: Stroke (The Basics)
Patient education: Subarachnoid hemorrhage (The Basics)
Patient education: Transient ischemic attack (The Basics)
Patient education: Arteriovenous malformations in the brain (The Basics)
Patient education: Aphasia (The Basics)
Patient education: Recovery after stroke (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Stroke symptoms and diagnosis (Beyond the Basics)
Patient education: Ischemic stroke treatment (Beyond the Basics)
Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis
Aneurysmal subarachnoid hemorrhage: Treatment and prognosis
Anticoagulant and antiplatelet therapy in patients with an unruptured intracranial aneurysm
Brain arteriovenous malformations
Prevention and treatment of venous thromboembolism in patients with acute stroke
Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis
Spontaneous intracerebral hemorrhage: Acute treatment and prognosis

The following organizations also provide reliable health information.

●National Library of Medicine

     (https://medlineplus.gov/healthtopics.html)

●National Institute of Neurological Disorders and Stroke

(www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page)

●American Stroke Association

     (www.stroke.org)

●Several books are also recommended:

•Caplan LR, (ed). Caplan’s stroke: A clinical approach, 5th edition, Cambridge University Press, Cambridge 2016.

•Hutton C, Caplan, LR. Striking back at stroke: a doctor-patient journal, Dana Press, New York 2003.

•Hutton C. After a stroke: 300 tips for making life easier, Demos, New York 2005.

•Caplan LR. Navigating the Complexities of Stroke, Oxford University Press, New York 2013.