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Stroke (Hemorrhagic)
Updated: 08/01/2003
Stroke is the third leading cause of hospitalization in the United States. A stroke is defined as the sudden reduction of blood flow to a portion of the brain. There are two main types of strokes: ischemic (also known as thrombotic) and hemorrhagic. A stroke of any type is an extreme medical emergency, and prompt treatment is imperative. Although hemorrhagic strokes account for only 15% of all strokes, they have a much higher mortality rate. There are two subcategories of hemorrhagic stroke: intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Although ICH and SAH are very similar, they generally result from different causes.
INtracerebral Hemorrhage (ICH)
Intracerebral hemorrhage is defined as the rupturing of cranial blood vessels, resulting in the leakage of blood into brain tissues. The most common risk factor for ICH is chronic hypertension; hypertension causes arteries and arterioles to become weakened, resulting in leakage. A Chinese study noted that there was considerable increased risk for ICH in hypertensive patients who did not regularly take their medications. Additional risk factors for ICH include drug and alcohol abuse, anticoagulant medications, age, gender, and race. Excessive alcohol consumption and drug use, particularly of cocaine and amphetamines, are the most common causes of ICH for people in their 20s and 30s. Anticoagulants, such as Coumadin or Heparin, are prescribed for a variety of conditions, including ischemic stroke, myocardial infarction, and deep vein thrombosis. Proper monitoring of these medications is essential because they increase the risk of ICH. Aspirin has also been shown to increase the risk of ICH in elderly patients. ICH rarely occurs in people under the age of 45, and the risk for developing ICH doubles every 10 years thereafter. Intracerebral hemorrhage occurs more frequently in men, and African-Americans are more likely to be affected than are Caucasians.
Symptoms of ICH include the following:
- Partial or total loss of consciousness
- Vomiting or severe nausea
- Weakness, numbness, or paralysis, especially on one side of the body
- Sudden, severe headache
If these symptoms occur, it is essential to receive immediate medical attention.
SUbarachnoid Hemorrhage (SAH)
A subarachnoid hemorrhage occurs when blood leaks into the membranes that surround the brain; the underlying causes for SAH include ruptured aneurysm (a ballooning of the arterial wall) and vascular malformations. Risk factors for SAH are more difficult to define than those for ICH but include age, gender, race, use of cigarettes and alcohol, and family history. The incidence of SAH increases throughout middle age, and peaks between the ages of 40 and 60. SAH affects women in 60% of all cases. African-Americans have nearly twice the risk as Caucasians. Cigarettes and alcohol abuse have been shown to increase aneurysm rupture. People with a family history of aneurysm-induced SAH are at higher risk because certain types of aneurysms appear to run in families.
Symptoms of SAH include:
- Sudden onset of severe headache
- Nausea or vomiting
- Stiff neck
- Light intolerance
- Total or partial loss of consciousness
After an aneurysm ruptures, a blood clot forms over the affected area. If the clot is disturbed, rebleeding occurs; rebleeding is the leading cause of death among SAH patients. It is critical that patients with the symptoms of SAH seek immediate medical attention.
DIagnosis of Hemorrhagic Stroke
The most common diagnostic procedures for determining the cause of hemorrhagic stroke are CT scan, MRI, and cerebral angiogram. These procedures are used to determine the type of stroke and the specific area of the brain that has been affected. Treatment of the stroke is based on the findings of these procedures.
COnventional Treatment of Hemorrhagic Stroke
Treatment of hemorrhagic stroke is based on the underlying cause of the hemorrhage and the extent of damage to the brain: treatment includes medication and surgical intervention. In patients with hypertension-induced ICH, initial treatment involves the use of antihypertensive agents. If the hemorrhage results from the use of anticoagulants, such as Coumadin or Heparin, these medications are discontinued immediately. Protamine and vitamin K may be given to reduce bleeding in patients with anticoagulant-induced bleeding.
In patients with ruptured aneurysms, surgical intervention is the method of treatment and includes placing a clip across the aneurysm or embolization if the damaged area is difficult to approach. During embolization, a wire-packed catheter is threaded through the blood vessels until it reaches the damaged area; the wires are then detached so that they form coils that attract blood cells to promote clot formation. Patients with ICH may benefit from a surgical evacuation of the hematoma. Surgical intervention is contra-indicated in patients who are 75 years old or older, who have significant pre-existing disease, or who arrive at the hospital in very poor condition.
Other Beneficial Treatment for Hemorrhagic Stroke
Hydergine, an antioxidant medication that helps to protect brain cells, may be beneficial for the treatment of hemorrhagic shock. In Europe, Hydergine is administered on an acute-care basis for the prevention of brain damage following stroke. The recommended dosage of Hydergine in an acute situation is 10 mg administered sublingually (under the tongue) and 10 mg given orally. Because the FDA has not approved Hydergine for use in the treatment of stroke, emergency room physicians may not be willing to administer this medication. Patients or their surrogates can, however, request that this medication be used. Hydergine has been approved in the treatment of other diseases, so it is available through the hospital pharmacy.
Piracetam, a nootropic medication similar to pyroglutamate (an amino acid), may be useful in the treatment of hemorrhagic stroke. Piracetam appears to protect brain cells from injury and death during stroke, thereby lessening the potential for permanent neurological damage. The recommended dosage for piracetam is 4800 mg a day taken orally. A recent Belgian study indicated that piracetam may be very beneficial if administered within 7 hours after the onset of stroke. Piracetam is not currently available in the United States.
Any disruption of blood flow to the brain causes massive free radical damage that induces much of the re-perfusion injury to brain cells characteristic of stroke. When blood flow is interrupted and subsequently restored (re-perfused), tissues release iron that provides a catalyst for the formation of free radicals that often permanently damage brain cells. The Life Extension Foundation has spent millions of dollars conducting research that involves developing methods of protecting the brain cells from injury caused by blood-flow disruption. The use of antioxidant nutrients, drugs and hormones, along with specific calcium-channel blockers and cell membrane stabilizing agents provide enormous protection to brain cells.
To learn about therapies that may strengthen arteries in the brain prior to hemorrhagic stroke, refer to the Life Extension Foundation's protocol on treating Cerebrovascular Disease. (To learn more about therapies that may restore neurological function following hemorrhagic stroke, refer to the Foundation's protocol for Age-Associated Mental Impairment [Brain Aging].)
Can Cholesterol Levels be too low?
Cholesterol has obtained such a bad reputation, that some people may be inadvertently killing themselves by intentionally keeping their serum cholesterol too low. At the American Heart Association's annual stroke conference (February 1999), a report was presented showing that people with cholesterol levels under 180 doubled their risk of hemorrhagic stroke compared to those with cholesterol levels of 230. Hemorrhagic stroke occurs when a blood vessel in the brain breaks open and is different than the more common thrombotic stroke caused by an abnormal blood clot. This study also showed that the risk of thrombotic stroke was twice as likely in those with cholesterol levels over 280 compared to those at 230. The report concluded that the optimal cholesterol level for overall stroke prevention was around 200.
Some Foundation members have been pushing their cholesterol levels way below 180. In the few reports of hemorrhagic stroke suffered by Foundation members, their cholesterol levels have all been far below 180 mg/dL.
Mid-Life Blood Pressure A New Risk Factor
A 30-year study of male twins showed that elevated blood pressure in mid-life predisposed men to accelerated brain aging and an increase in stroke later in life. Men with even mildly elevated blood pressure 25 years before showed smaller brain volumes and more strokes compared to their twin brothers who did not have the elevation in blood pressure. This study, published in the journal Stroke (1999;30), emphasized the importance of aggressively treating elevated blood pressure even if it is not grossly abnormal. (Refer to the Foundations Hypertension protocol for information about blood pressure control therapies and diets.)
Conclusion
Hemorrhagic stroke is a medical emergency. The two types of hemorrhages involved are ICH and SAH. The primary risk factor for ICH is hypertension because chronic hypertension weakens blood vessels. Other risk factors include drug and alcohol abuse, anticoagulant medications, age, gender, and race. The underlying cause for SAH is cerebral aneurysm. Risk factors for SAH include family history of aneurysm, age, gender, and race. Symptoms for both types of hemorrhagic stroke are similar and include sudden onset of severe headache, loss of consciousness, nausea and vomiting, and partial or total paralysis. Diagnosis of the underlying cause of hemorrhagic stroke is by CT scan, MRI, and angiography. Treatment for hemorrhagic stroke depends on the underlying cause. For ICH resulting from hypertension, the initial treatment is blood pressure control. If anticoagulants are the cause of ICH, these medications are immediately discontinued. Surgical evacuation of the hematoma may be necessary. For SAH, treatment includes clipping or embolization of the aneurysm. The medications Hydergine and piracetam may be beneficial to patients with hemorrhagic shock. The FDA has not approved Hydergine for the treatment of stroke, but it should be available through the hospital pharmacy, and patients or their surrogates should request its use. Piracetam may be beneficial in preventing permanent neurological damage following stroke. Piracetam is not currently available in the United States.
Summary
The symptoms of intracerebral hemorrhage (ICH) include nausea and vomiting; sudden, severe headache; weakness, numbness; paralysis, particularly to one side of the body; and partial or total loss of consciousness. The symptoms of subarachnoid hemorrhage (SAH) include sudden, severe headache; nausea and vomiting; stiff neck; light intolerance; and partial or total loss of consciousness.
Diagnostic procedures for hemorrhagic stroke include CT scan, MRI, and cerebral angiogram.
Treatment of hemorrhagic stroke consists of medication and surgical interventions, based on the underlying cause of the hemorrhage. Controlling high blood pressure is essential to preventing further strokes.
Hydergine, an antioxidant medication that protects brain cells, may be given in an acute situation. The recommended dosage is 10 mg given sublingually and 10 mg administered orally. Because the FDA has not approved Hydergine for this purpose, the patient or patient's advocate should request that the medication be given.
Piracetam, a nootropic medication, may be useful in the prevention of hemorrhagic stroke because it appears to protect brain cells from injury during the stroke event. The recommended dosage for piracetam is 4800 mg a day, administered orally.
Consider taking 500 mcg to 10 mg of melatonin (at night) and 100-200 mg of palm-oil tocotrienols a day to protect against further free-radical-induced brain cell injury.
For more information
Refer to the Cardiovascular Disease: Comprehensive Analysis
Contact the National Institute of Neurological Disorders and Stroke, 800-352-9424.
Product availability
Hydergine tablets and Piracetam can be ordered from off-shore suppliers who will ship to the United States for personal use. For a list of offshore suppliers of these medications phone 1-800-544-4440 or order online. |