Ask Us Anything About… Hemorrhagic Stroke

Scott Gilbert – From Penn State Health, this is Ask Us Anything About Hemorrhagic Stroke. I’m Scott Gilbert. Well, there are two main types of stroke, one caused by a blood clot. The other caused when an artery ruptures. Our focus today is on the latter, known as the hemorrhagic stroke. Here to answer our questions about the symptoms, causes, and treatments for hemorrhagic stroke is Dr. David Wilkinson, a Neurological Surgeon at Penn State Health Milton S. Hershey Medical Center. Dr. Wilkinson, good to have you with us today. Maybe we could start by having you walk us through what happens inside the brain in a hemorrhagic stroke and kind of what makes it different than ischemic stroke.

Dr. Wilkinson – Great. Yeah, thanks, Scott, and thanks so much for having me. It’s an honor to be on. So yeah, you know, exactly like you said. So an ischemic versus a hemorrhagic stroke sometimes a, you know, ischemic stroke which is the more common type, is really a blockage stroke where a blood vessel is blocked. And so the brain that gets blood from that, you know, isn’t getting the blood that it should. In a hemorrhagic stroke or a bleeding stroke, that’s when we see blood being outside the vessels really in a space where it’s not supposed to be. And that can be within the brain itself. And we call that an intracerebral hemorrhage. Or it can be in some of the area that surrounds the brain. But, you know, overall, it’s a stoke where blood has gotten outside the vessels where it’s usually supposed to be. And then that can cause injury and irritation to the brain that’s around it.

Scott Gilbert – Yeah, so what causes more damage then, the initial rupture itself or the build-up of blood and then the pressure it exerts on nearby tissue?

Dr. Wilkinson – Yeah, also a great question. So I think it can differ for each patient. So in a lot of patients, particularly those who have rupture of an aneurysm, which I think of a little bit, that can be kind of a catastrophic event where the pressure all of a sudden gets out. And that, unfortunately, can be almost instantly fatal. Sometimes though, it’s more of a — more of a leak. And so people just have a bad headache. But the blood has leaked out, and they’re still awake. They’re still able to talk. But then, hours or even days later, that blood can cause irritation and can cause, you know, dysfunction of the brain around it. So I think the short answer to question is it depends. And in some cases, it can be that initial rupture which injures us so much. But then, in others, it’s days later the blood products that the body is trying to absorb are causing irritation and causing problems.

Scott Gilbert – And when it comes to hemorrhagic stroke versus ischemic, is one thought to be or typically more severe than the other?

Dr. Wilkinson – Yeah, that’s also a good question. So you can have — you can have a mild or a severe stroke of either type. And so, you know, there are probably more minor ischemic strokes where people have minimal symptoms. You can even have what’s called a TIA or a transient ischemic attack where the symptoms go away. And hemorrhagic strokes are usually, you know, a little bit more severe and certainly on a, you know, the higher percentage of people I think with hemorrhagic strokes can have severe ones and go on to pass away, unfortunately.

Scott Gilbert – You’re watching Ask Us Anything About Hemorrhagic Stroke from Penn State Health. I’m Scott Gilbert alongside Dr. David Wilkinson. He’s a Neurological Surgeon at the Milton S. Hershey Medical Center. And we welcome your questions, your comments. You can add them to the comment field here below this Facebook post. We’ll pose those questions to him live, or if you’re watching this interview on playback, we’ll get you a typed-out response to your question. But we do address all questions to the best of our ability. So you know, with stroke, Dr. Wilkinson, we often hear the acronym BEFAST, each letter standing for a particular symptom or something to remember. Does BEFAST apply with a hemorrhagic stroke as well?

Dr. Wilkinson – Yeah, good question. So BEFAST does apply to a hemorrhagic stroke because patients can exhibit those same symptoms. And just to walk through, you know, for those who haven’t heard it. So BEFAST, so the B stands for balance. So if somebody, you know, has lost, you know, is having trouble balancing. The E stands for eyes. So sometimes, if their eyes are going one way or the other and they don’t seem to be moving around normally or looking straight ahead. The F stands for face. So if somebody has drooping on one side of the face, that’s a sign of stroke. The A stands for arms. So you know, if you ask them to lift their arms, sometimes they’ll be able to lift one but not the other. And then the ST go together. That’s for speech testing, so if they’re having problems speaking. So any of those can be affected by hemorrhagic stroke. The one additional thing that you need to be aware of with hemorrhagic stroke is usually, hemorrhagic stroke or bleeding strokes, people have severe headaches. And you don’t necessarily have that with the — actually, most often, you do not have that with an ischemic stroke. So patients with a bleeding stroke, especially one from a ruptured aneurysm, a lot of times they talk about having, you know, the sudden onset of the worst headache of their life, which is one way that sometimes you can differentiate it. And sometimes headache will be the only symptom actually. So sometimes they won’t have any of those BEFAST signs that we talked about. But they’ll just have a severe headache. So that’s really the, I think, the addition to BEFAST that’s important to think about for hemorrhagic stroke is, you know, people having a headache. Now, it can be difficult because, you know, headaches are quite common in the general population. But what we, you know, what we think about is — or what we really get concerned about is that headache, you know, unlike any headache you’ve ever had before. We, you know, the term worst headache of your life is a lot of time what we’re thinking about when people have a headache or when people have a hemorrhagic stroke.

Scott Gilbert – And a rather sudden onset of that headache, right? So it’s that initial bursting of the blood vessel that causes the pain, not so much the gradual blood build-up over time?

Dr. Wilkinson – I think it can be both. But you’re right. It most often is a sudden onset headache, especially with a ruptured aneurysm. But I wouldn’t, you know, if you have a severe headache, I wouldn’t discount it just because it, you know, just because it didn’t necessarily come on really suddenly. And this is hard, you know, for people who have migraines, who are headache sufferers. You know, it can be hard to differentiate sometimes.

Scott Gilbert – I would think so. This is Ask Us Anything About Hemorrhagic Stroke from Penn State Health. We’re getting some great information today from Dr. David Wilkinson. He’s a Neurological Surgeon at the Milton S. Hershey Medical Center. We welcome your questions, your comments. Just add those to the comment field, and we’ll get to those as quickly as we can here over the course of this interview. When someone is experiencing stroke symptoms, is it better for them to, you know, I would say: drive themselves to the hospital? Probably not. Be driven to the hospital by a loved one, or call 9-1-1? What’s the best course of action?

Dr. Wilkinson – Yeah, so definitely 9-1-1, you know. And that’s because, you know, that’s the fastest way to get them the care that they need. Even if you think, you know, hey, I could drive them to the hospital pretty quickly. You know, the first responders who, you know, who can come with 9-1-1, they can actually, you know, one of the — one of the things we try to do is treat this as quickly as we can and they, you know, if they have a suspected stroke victim, they’ll call ahead and so they’ll have everybody, you know, ready and waiting for them at the, you know, at the hospital. They can start mobilizing people to, you know, to give drugs or provide therapy that’s needed. Stroke is one of these things where every second counts, you know. They say time is brain. And so I would absolutely recommend calling 9-1-1, you know, if you suspect somebody is having a stroke, either a bleeding stroke or a blockage stroke or, as we say, ischemic or hemorrhagic strokes.

Scott Gilbert – And like you say, they can get the team ready, especially if they’re having like a comprehensive stroke center like the Milton S. Hershey Medical Center, right?

Dr. Wilkinson – That’s exactly right, yup.

Scott Gilbert – What are some of the causes. People are probably wondering, well, how do I avoid having a hemorrhagic stroke? Sounds kind of scary. What are the best ways to reduce your risk factors for one?

Dr. Wilkinson – Yeah, yeah, good question. So the best way, you know, there’s things you can control and things you can’t. So the number one things you can, or at least have some control on, is smoking is a big risk factor. So smoking also, you know, excessive alcohol use can be a risk factor. And then blood pressure control. A lot of the, you know, a lot of the times, people who have these have had blood pressure problems. Other risk factors that you, you know, that we can’t control, age is, you know, these are more common as we get older. In aneurysms, women are actually more affected than men, and so for reasons we don’t completely understand. But the main ones, you know, things you can do something about, the main ones would be smoking and controlling your blood pressure.

Scott Gilbert – And how about arteriovenous malformation? Can you talk about what that is, what’s going on inside the vessels, and how that can lead to one?

Dr. Wilkinson – Yeah. Yeah, great question. So an arteriovenous malformation is sort of a tangle of vessels that are abnormal. And so usually, you know, blood goes from a high-pressure artery, then it goes through capillaries, and then it goes to a vein. In arteriovenous malformation, it sort of skips that capillary phase. And so you have high-pressure blood that’s in vessels that are not normal. And so they’re a little bit thinner than normal. And these we generally think of as congenital, or you’re born with them. And so often, they’re one of the most important causes of hemorrhagic stroke, particularly in young people. Children or, you know, people in their 20s or 30s when they have an intracerebral hemorrhage, it’s often due to an arteriovenous malformation.

Scott Gilbert – Now, when it comes to arteriovenous malformations, aneurysms for that matter, it sounds like they lurk silently in there. Is there any way that they can be spotted and even fixed before they lead to a stroke?

Dr. Wilkinson – Yeah, also a good question. Yeah, so you mentioned arteriovenous malformations, and then aneurysms are a little bit different. So aneurysms, we generally don’t think you’re born with them. And they develop as we age. Again, smoking and blood pressure are things that can be associated with those. And like you said, we usually don’t know they’re there until they rupture. Aneurysms are probably more common than most people think. I think general probably about three percent of people in the general population have an aneurysm, but the — or have a brain aneurysm. But the majority of them, we don’t know about it, and they don’t cause a problem. Increasingly we’re seeing these found incidentally. So someone has, you know, imaging for another reason, and they see the aneurysm. And there are things we can do to treat the aneurysm before it rupturing. And each aneurysm needs to be evaluated to evaluate whether the risks of treatment outweigh the benefits. As I mentioned, most aneurysms will not rupture, but certainly, some may. And that can be one of the hard things is figuring out which, you know, if one is found, figuring out if it’s at risk for rupturing, if it’s, you know, if the risks of treatment are outweighed by the benefits of treatment.

Scott Gilbert – We welcome your questions for Dr. Wilkinson. Just add them to the comments here below the Facebook chat. And we’ll add those to the list and get those questions answered for you as part of this interview. Now, Dr. Wilkinson, I am — with an ischemic stroke, the treatment goal is to clear the blockage, of course. How are hemorrhagic strokes treated?

Dr. Wilkinson – Yeah. Yeah, great question. So it differs by the type of hemorrhagic stroke. So the first one I’ll talk about is subarachnoid hemorrhage. And so that’s bleeding into the area kind of surrounding — immediately surrounding the brain. Excuse me. And the most common cause except for trauma of that is of an — they’re caused by ruptured aneurysm. And so the main thing we do first to treat that is to secure the aneurysm. That’s either done through the vessel — excuse me — through the vessel. We can sometimes put coils in it. Or by doing open surgery where you open up and take off part of the skull. You can go in and put a clip across the aneurysm. And you know, whoever is treating you will recommend the best one for your particular aneurysm and for that particular patient. Intracerebral hemorrhage, which is bleeding within the brain itself, oftentimes we just need to control the blood pressure and monitor those patients. Most patients with intracerebral hemorrhage don’t need to have surgery. But there are some who do based on the size of the hemorrhage or, you know, if there’s something underlying like an arteriovenous malformation.

Scott Gilbert – Your watching Ask Us Anything About Hemorrhagic Stroke from Penn State Health. We have a few minutes left with Dr. David Wilkinson. We welcome your questions in the comment [inaudible] here below this Facebook post. So I’m curious about how the brain recovers after a stroke because the brain does have some pretty cool and unusual powers to do so in many cases. For example, if blood flow is restored to a section of the brain that was affected, I understand it can actually resume function, right?

Dr. Wilkinson – It can, yeah, it generally has to be restored pretty quickly and, you know. So that’s why in — particularly in blockage strokes, we really try to restore blood flow as quickly as we can. The brain in hemorrhagic stroke it’s a little bit different. A lot of people’s dysfunction and problems that they get can be caused by pressure. And so often, there’s things we’ll do like putting in a drain to relieve that pressure. And once that pressure is relieved, the brain can function better. One of the amazing things, particularly in young patients, is that you know, patients can recover. And there can be reprograming where, you know, that a part of the brain takes over a function that used to be performed by a different part of the brain. And you know, and we call that neuroplasticity, which again, is easier when we’re young. It’s a little bit harder in, you know, when patients are older and have strokes. But there are, yeah, there are ways in which the brain can recover. And we see in patients who’ve had a ruptured aneurysm we see their recovery continue usually over the course of at least months, sometimes up to a year, they can continue to progress in their recoveries.

Scott Gilbert – Sounds good. We have a question now from Trishia. [phonetic] I hope I’m saying your name right. “Is there any type of skin rashes or anything like that,” she asks, “that may develop or anything visible on the skin from veins and arteries when someone has hard to control high blood pressure, arteriostatic blood pressure, diabetes, and such that puts them at a higher risk of stroke? If so, what are some remedies?” So talking about skin rashes kind of external evidence of such issues.

Dr. Wilkinson – Yeah, usually you know, not that I’m aware of is there any, you know, particular skin findings where you can, you know, know for sure that you have blood pressure problems. Really the best thing, you know, if you do have things like high blood pressure or hypertension or diabetes, is to have those monitored regularly, you know, by seeing your family doctor and have those things checked.

Scott Gilbert – Thank you for that question. You know, I’m curious, Dr. Wilkinson, what factors determine the long-term effects that a hemorrhagic stroke will have? Because as we know, some people recover almost fully if not completely. Some people don’t survive it.

Dr. Wilkinson – Yeah. So the best predictor of how somebody is going to do long-term is the initial — is how they present initially or how they show up to the hospital. So you know, for people with ruptured aneurysms, one of those sort of rules of thumb is that, you know, unfortunately, a third don’t make it to the hospital. And then a third are, you know, pretty disabled and go on to have, you know, impaired function and then a third, you know, make good recoveries. And you know, oftentimes return to what they were doing before, return to their work and family. But the best predictor is how severely affected somebody is when they initially present to the hospital. It’s not the only predictor. There are other things. The type of bleed and the location of the bleed can affect that also.

Scott Gilbert – Okay, real interesting stuff, very helpful to know. Dr. David Wilkinson, Neurological Surgeon at Hershey Medical Center, thanks for taking the time to talk today. I appreciate it.

Dr. Wilkinson – Great. Thank you. Thanks so much.

Scott Gilbert – And I want to thank everybody who tuned in, those who asked questions here for Ask Us Anything About Hemorrhagic Stroke from Penn State Health.

Dr. Wilkinson – Thanks, Scott.