Stroke: Hemorrhagic Stroke
Guest: Dr. Angela Hays - Neurosciences
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Angela Hays, who is Assistant Professor of Neurosciences here at the Medical University of South Carolina. Dr. Hays is a neurology intensivist. In other words, she takes care of gravely ill patients with various forms of neurological injury. Dr. Hays, in this podcast, let’s talk about a kind of stroke called hemorrhagic stroke. First of all, there are two kinds of stroke, thrombotic stroke and hemorrhagic stroke. Can you explain the difference between the two?
Dr. Angela Hays: Absolutely. A thrombotic stroke, or an ischemic stroke, comes about when somebody has a blockage of the blood flow to a part of the brain. That usually can come from the formation of a clot at the blood vessel site, or it can, occasionally, come from clots that break off of other sources. For instance, the most common would probably be the heart. Hemorrhagic stroke results from a different mechanism. It comes about when a blood vessel ruptures and you end up having bleeding into the brain tissue. This latter type of stroke is much more serious and, unfortunately, the recovery rates tend to be a lot lower, and our options for treatment are significantly more restricted than with the clotting type of stroke.
Dr. Linda Austin: Who gets this type of stroke?
Dr. Angela Hays: Well, the single biggest risk factor for a hemorrhagic stroke is high blood pressure. Specifically, we worry about those patients whose blood pressure is uncontrolled or difficult to control. We very commonly find patients who come in with a hemorrhagic stroke several days after they’ve run out of their antihypertensives and maybe didn’t have a chance to refill them. So, that’s really a significant risk that I don’t think many of our patients appreciate.
Dr. Linda Austin: That it’s really important to stay on your antihypertensive medications?
Dr. Angela Hays: Absolutely. And some of these medications, clonidine is the one that comes to mind, if you stop it abruptly, for instance, if you ran out and were unable to get back to the pharmacy for a refill, you can actually have a really profound increase in your blood pressure, almost like a withdrawal syndrome.
Dr. Linda Austin: Or a rebound, sort of?
Dr. Angela Hays: Exactly.
Dr. Linda Austin: I see.
Dr. Angela Hays: And that can be really dangerous, and can result in bleeding on the brain or bleeding into the brain tissue, or a hemorrhagic stroke, as we’ve been talking about.
Other reasons that somebody might have something like this has to do with certain malformations of the blood vessels, the most common would be something called an arteriovenous malformation. But that kind of hemorrhagic stroke is a lot less common than the ones related to high blood pressure.
Dr. Linda Austin: Is there a threshold of blood pressure at which point hemorrhagic stroke is very likely, or does it vary from person to person?
Dr. Angela Hays: It varies from person to person. It would be nice if we had a straightforward cutoff. But, really, what ends up happening is that somebody who has had elevated blood pressure for a long period of time starts to develop changes in the wall of the blood vessel that makes them more prone to these kinds of tears. Diabetes is also a risk factor. So, somebody who has diabetes in association with high blood pressure will produce those changes more rapidly. That process can be slowed down, as I said, by controlling your blood pressure and, also, if you happen to have diabetes as well, to keep that under really tight control.
Other things that can be associated with this kind of stroke include smoking, which is also a serious risk factor for the thrombotic or ischemic type of stroke, and alcohol use. We find that, as with the heart, maybe one drink a day or one drink every other day might be somewhat protective. But patients that drink several drinks a day, up to two or three, will find themselves to be at increased risk of hemorrhagic stroke.
Dr. Linda Austin: Do you ever see one of these strokes, just out of the blue, in someone that you think of as kind of a young healthy person?
Dr. Angela Hays: We do. There are a couple of situations in which that might occur. It’s not uncommon for us to have patients who are in their 30s or 40s who say they’ve never been to a doctor and they don’t have a history of high blood pressure. But then frequently, in that situation, what we find is, when we look hard enough, we find evidence that the blood pressure has been high for awhile and they just simply didn’t know because they’ve never been seen by a healthcare practitioner.
Other situations include people who have been using certain medications that can artificially raise the blood pressure. Certain kinds of substances that somebody might use that could cause that would be cocaine, certainly, certain diet aids, amphetamines, Ritalin. Those can all cause artificial elevations of the blood pressure that can lead to these kinds of symptoms.
Dr. Linda Austin: How about birth control pills?
Dr. Angela Hays: Birth control pills are an interesting problem. They do increase the body’s tendency to form clots and can be a risk factor for the thrombotic or ischemic strokes. But I’m not aware that they’ve been determined to be a risk factor for hemorrhagic strokes. The other thing to watch out for with the birth control pill is that, in cases where women are dehydrated, it can predispose people to what’s called a venous thrombosis, which can also result in dangerous neurological symptoms.
Dr. Linda Austin: What are some of the common early symptoms of a stroke?
Dr. Angela Hays: Well, either kind of stroke, hemorrhagic or ischemic, can present with symptoms that usually involve just one side of the body, although that’s not always a hard and fast rule. It usually starts out with numbness, tingling, or weakness on the affected side. Other things that you might see include difficulty speaking, commonly we describe this as word finding difficulty, meaning that the patient knows what they want to say but can’t seem to get the words out. Or, in a different scenario, they may be babbling incoherently and have no trouble getting the words out. It’s just that they’re speaking in a way that no one else can understand.
The hemorrhagic type of stroke, specifically, often presents with a headache or nausea and vomiting, which isn’t that common with the clotting kind of stroke. And, very occasionally, these symptoms can present with abnormalities of the facial nerves or with confusion and loss of consciousness, but that’s significantly less common.
Dr. Linda Austin: I want to talk about the diagnosis and treatment of these strokes, but let’s take a break now and do that in another podcast.
Dr. Angela Hays: Okay.
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