Treating Hemorrhagic Stroke

As soon as a hemorrhagic stroke is diagnosed, the immediate goal is to prevent a second hemorrhage. There are two basic options, surgery or medication, but no definitive information on which option is best for which people. The decision is generally made on a patient-by-patient basis. The doctors will also decide whether medication is needed for blood pressure, clotting abnormalities, or other underlying conditions.

Ongoing clinical research studies are testing the best ways to control or prevent the complications of brain swelling and the expansion of intracerebral hemorrhage in both deep and lobar hemorrhages. Clinical researchers are also testing the safety and effectiveness of interventional arterial procedures to obliterate berry aneurysms or AVMs.

Coiling

If a cerebral aneurysm caused a first hemorrhage, a second one may be prevented with an inter-arterial procedure known as coiling. The surgeon inserts a catheter through the arm or groin into a large artery and works it through the aorta up to the site of the aneurysm in the brain. Then the doctor releases a tiny coiled ball inside the aneurysm (see Figure 15). The coil makes the blood in the aneurysm clot. Once this happens, the aneurysm is no longer dangerous.

Surgery

There are different surgical procedures for preventing a second hemorrhage, depending on the cause of the bleeding. For strokes caused by an aneurysm, the surgeon opens the skull, clamps the base of the aneurysm to prevent another rupture, and removes the accumulated blood. For hypertensive intracerebral hemorrhages, the surgeon may remove excess blood from the hematoma, to lessen pressure. This procedure is particularly effective in people with cerebellar hemorrhage.

The timing of surgery is crucial. In the case of a ruptured berry aneurysm at the base of the brain, for example, surgery and coiling are usually performed within two days. This effectively reduces the risk of rebleeding and helps wash clotted blood away from the artery. If clotted blood remains, it can cause a condition called cerebral vasospasm.

Cerebral Vasospasm

Cerebral vasospasm is the uncontrolled constriction of arteries at the base of the brain.

About one-third of people with subarachnoid hemorrhages have a cerebral vasospasm within 4–14 days. Although researchers still don't fully understand what causes vasospasm, it seems to be triggered either by substances released as a blood clot breaks down or by a clot surrounding the artery at the base of the brain and depriving the blood vessel of nutrients from spinal fluid. Vasospasm can be so severe that it impairs blood flow to the brain, causing additional damage and even death. People with a subarachnoid hemorrhage should have a CT scan done right away to detect blood clots so doctors can locate the aneurysm and predict where vasospasm may occur.

The treatment for vasospasm is not always effective. Options include administering intravenous fluids to increase blood volume, using drugs to raise blood pressure, or giving medication, such as nimodipine (Nimotop), that relaxes the muscles in vessel walls. In some cases, it may be necessary to dilate the vessel with a balloon catheter or inject medicine directly through a catheter in the artery near the vasospasm. Because of the serious risks involved, which include rupturing the artery, this procedure requires a highly skilled and experienced team of physicians.

Medication

Drug therapy may be needed to control blood pressure that is too high or too low, or to reduce brain swelling. While these medications are being administered, patients with hemorrhagic stroke remain in the intensive care unit so that their conditions can be closely monitored.