What are hemorrhagic strokes and how do they occur?

From the Guidelines

Hemorrhagic strokes are a type of stroke that occurs when a blood vessel in the brain ruptures or leaks, causing bleeding into or around brain tissue, and are typically more severe than ischemic strokes, accounting for about 10% of all strokes. They happen through two main mechanisms: intracerebral hemorrhage, where bleeding occurs directly into brain tissue, and subarachnoid hemorrhage, where bleeding occurs in the space between the brain and surrounding membranes 1. The primary causes include uncontrolled high blood pressure (hypertension), which weakens blood vessels over time; cerebral aneurysms, which are balloon-like bulges in arteries that can rupture; arteriovenous malformations (abnormal connections between arteries and veins); use of blood thinners like warfarin, heparin, or newer anticoagulants; and sometimes recreational drugs like cocaine or amphetamines.

Some key points to consider about hemorrhagic strokes include:

• They are the deadliest form of acute stroke, with early-term mortality about 30% to 40% 1
• Incidence of hemorrhagic strokes increases sharply with age and is therefore expected to remain substantial as the population ages 1
• The use of anticoagulants is a growing source of hemorrhagic strokes, which may counterbalance the reduced risk associated with increasing prescription of direct oral anticoagulants (DOACs) relative to vitamin K antagonists (VKAs) 1
• Hemorrhagic strokes are in need of novel treatments and improved application of established approaches for every aspect of the disease: primary and secondary prevention, acute inpatient care, and poststroke rehabilitation and recovery 1

When bleeding occurs, it creates pressure within the skull, damages surrounding brain cells, and disrupts normal brain function. The accumulated blood can also irritate brain tissues, causing swelling and further damage. Symptoms typically appear suddenly and include severe headache, weakness or numbness on one side of the body, difficulty speaking, vision problems, loss of balance, and sometimes loss of consciousness. The management of patients with spontaneous intracerebral hemorrhage requires prompt recognition and action, including efficient clinical assessment, blood pressure and coagulopathy management, and access to neurosurgery 1.

From the Research

Definition and Causes of Hemorrhagic Strokes

• Hemorrhagic strokes are a type of stroke that occurs when a blood vessel in the brain ruptures, causing bleeding in or around the brain 2.
• They account for approximately 15% of strokes worldwide and can be classified into different types, including deep (basal ganglia, brainstem), cerebellar, or lobar hemorrhages 2.
• The causes of hemorrhagic strokes can vary, but common risk factors include hypertension, cerebral amyloid angiopathy, and arteriolosclerosis 2, 3.

Mechanisms of Hemorrhagic Strokes

• Hemorrhagic strokes can occur due to the rupture of blood vessels in the brain, which can be caused by various factors such as high blood pressure, vascular malformations, or aneurysms 2, 4.
• The rupture of blood vessels can lead to bleeding in the brain, which can cause damage to the surrounding brain tissue and lead to neurological deficits 3.
• The mechanisms of hemorrhagic strokes can also involve complex interactions between edema, inflammation, iron-induced injury, and oxidative stress 3.

Risk Factors and Predictors

• Certain risk factors, such as age, gender, and comorbidities like hypertension, atrial fibrillation, and diabetes mellitus, can increase the likelihood of developing a hemorrhagic stroke 5.
• Predictors like higher NIHSS score, larger infarction size, and cardioembolic strokes can also make an individual more susceptible to developing hemorrhagic transformation 5.
• Other risk factors, such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels, can also contribute to the development of hemorrhagic strokes 5.

Treatment and Management

• The treatment and management of hemorrhagic strokes can involve various strategies, including medical and surgical interventions 6, 3.
• The goal of treatment is to reduce the risk of hematoma expansion and rebleeding, and to improve outcomes for patients with hemorrhagic strokes 6.
• Ongoing research into novel approaches for hemorrhagic stroke management provides hope for reducing the devastating effect of this disease in the future 3.