Types of Strokes and Treatment Options
There are two types of strokes that can occur in blood vessels: hemorrhagic and ischemic. A hemorrhagic stroke is when a blood vessel breaks in the brain causing blood to seep into brain tissue. Ischemic strokes are more like heart attacks, when clots block blood flow to the brain’s cells.
A hemorrhagic stroke occurs when a blood vessel in the brain breaks, spilling blood into the brain. Hemorrhagic strokes are an emergency and immediate attention is extremely important. Hemorrhagic strokes are not as common as ischemic strokes, accounting for only about 15 percent of all strokes, but are responsible for more than 30 percent of all stroke deaths.
There are two types of hemorrhagic strokes:
An intracerebral hemorrhage is caused when a blood vessel within the brain tissue ruptures or breaks, and a subarachnoid hemorrhage is caused when a blood vessel ruptures and blood is spilled around the surface of the brain and under the protective arachnoid layer. While both of these strokes are a result of ruptured blood vessels, they arise from different causes.
Intracerebral hemorrhage (ICH)
Intracerebral hemorrhage is the most common type of hemorrhagic (bleeding) stroke. This bleeding is the result of a broken blood vessel inside the brain tissue.
Signs and symptoms
Signs and symptoms of a hemorrhagic (bleeding) stroke are not always the same and will depend on where the ruptured vessel is located in the brain and the amount of bleeding. Symptoms of ICH are almost always sudden and may include:
- Sudden, severe headache
- Vomiting or severe nausea
- Sudden numbness or weakness of the face, arm or leg on one side of the body
- Confusion or loss of consciousness
If you experience any of these symptoms, don't wait. Call 911 and get to the nearest hospital that can treat acute strokes.
The most common cause of intracerebral hemorrhage is high blood pressure. Another cause is an arteriovenous malformation (AVM), which is a cluster or tangle of blood vessels that are abnormal and weak. These weak blood vessels can break easily and are usually seen in younger patients (20-40 years old).
The treatment of ICH will depend on the exact cause and size of the stroke and may include:
- Reducing and controlling blood pressure.
- Surgery to remove blood within the brain tissue or the abnormal vessels (AVM).
- Catheters inserted into the brain to drain the excess fluid.
- Medications and blood products to help the blood clot properly, especially for people who take blood-thinning medications.
Subarachnoid Hemorrhages (SAH)
Subarachnoid hemorrhages result in blood spilling into the protective spaces surrounding the brain.
Signs and symptoms:
Many times there is no warning of an SAH. Sometimes blood will begin to leak before the blood vessel breaks completely. The most common symptoms of an SAH include:
- Sudden, severe headache usually described as "the worst headache of my life"
- Nausea and vomiting
- Sensitivity to light
- Stiff neck
- Loss of consciousness
There is no single cause of SAH but the most common is the result of a ruptured or broken aneurysm. An aneurysm is a balloon-like bulge protruding from an artery wall. Blood fills the aneurysm and, like a balloon, the larger it gets the weaker it becomes until it "pops" or ruptures. More than half of the subarachnoid hemorrhages (SAH) are caused by ruptured aneurysms.
Treatment of SAH depends on the cause of the bleeding. Medications or surgery may be used to treat hemorrhages not caused by aneurysms (high blood pressure, drug interaction, etc.)
Aneurysm ruptures are usually treated by either sealing the aneurysm from the outside or sealing it from the inside. Doctors consider several factors when deciding which treatment option is best:
- Size, location and type of the aneurysm
- Condition of the patient
- Medical history of the patient
Clipping is still the most common surgical treatment for brain aneurysms. This treatment seals the aneurysm from the outside and requires general anesthesia. An incision is made into the skull and a section of bone is removed. The surgeon then surgically enters the brain and, using a microscope, carefully separates the aneurysm from the normal blood vessel and clips it with a tiny clip, similar to a clothespin. The clip stops blood from entering the aneurysm.
This treatment seals the aneurysm from the inside and involves using a tiny catheter that is threaded from the groin artery up into the brain artery and into the aneurysm. Tiny platinum coils are released and packed inside the aneurysm to seal it off. With the advent of this new treatment, some patients who were told their aneurysm was inoperable now have hope for a treatment. For other patients who, because of advanced age, medical condition or other factors could not tolerate open brain surgery, this could be an alternative to their treatment.
Ischemic strokes are caused by a blood clot in an artery in the brain. About 80 percent of strokes are ischemic. Symptoms can be similar to hemorrhagic strokes and may include sudden numbness, sudden speech or vision problems, confusion or severe headache.
Treatments available for these types of strokes are time-sensitive, which makes recognition of stroke symptoms and rapid access to medical care critical. In addition, some treatment options are only available at specialized stroke care centers, like the INI.
Intravenous tissue plasminogen activator (t-PA) is a medication that dissolves blood clots quickly and restores the flow of blood to the brain tissue. It is commonly referred to as the "clot buster." It was approved by the FDA in 1996 to treat ischemic-type strokes.
t-PA has been approved to treat brain attacks in the first three hours following the onset of symptoms. If given promptly, 1 in 3 patients who receive t-PA resolve their symptoms or have major improvement in their stroke symptoms.
Bleeding (hemorrhage) is the most common risk that can occur. In 6 out of 100 patients bleeding may occur into the brain or other parts of the body. This bleeding into the brain could be serious enough to cause death; therefore certain conditions may exclude some individuals from receiving this treatment. Also, stroke sufferers arriving at a hospital outside of the three-hour time window may not be eligible to receive this treatment as benefits may not outweigh risks. Other indications or medical conditions may also preclude t-PA treatment, such as:
- Bleeding in the brain present on the initial brain imaging
- A history or presence of a brain aneurysm or other structural brain abnormalities
- Recent heart attack
- Serious head trauma within the last three months
- Major surgery within previous 14 days
- Bleeding disorders
- Use of blood thinners, such as Coumadin
- Uncontrolled high blood pressure
Surgery and Other Procedures
Brain cells that do not receive the proper amount of blood flow begin to die within minutes. It takes only 12 minutes for a pea-sized area of brain to die during an ischemic stroke. Removing or dissolving the clot that blocks blood flow must be done quickly in order to save surrounding brain tissue.
Blood clotting medications can also be used intravenously at that site of the clot, in a procedure called Intra-arterial t-PA. Though this cutting-edge treatment is still experimental, and not yet approved by the FDA for strokes, research results and expert guidelines support the use of Intra-arterial t-PA within 6 hours of the onset of stroke symptoms.
This treatment involves making a small incision in the groin area and inserting a catheter into the femoral artery. The catheter is guided through the arteries of the body up to the brain. Dye is injected into the arteries to discover any abnormalities such as a clot that may be obstructing blood flow to the brain. If a clot is found, the t-PA medication can be injected through the catheter right to the clot site to help dissolve the clot.
Not all hospitals are capable of providing this type of treatment. The INI Stroke Center has highly-trained neuro-interventional radiologists who specialize in providing this treatment. The physician team will work closely with the patient and the patient’s family to discuss if this procedure is best.
The experts at the INI use two techniques for removing blood clots that may be obstructing blood flow, the MERCI Device and the Penumbra Device. Both treatments can be administered up to 8 hours following the onset of stroke symptoms. Both treatments also involve making a small incision in the groin area and inserting a catheter into the femoral artery, similar to the Intra-arterial t-PA. The catheter is guided up to the brain where dye is injected into the arteries to discover any abnormalities such as a clot that may be obstructing blood flow to the brain.
If a clot is found, one of two devices is guided through the catheter to the clot site and is used to carefully remove the clot from the artery. The MERCI Device is a small device shaped like a cork screw that is implanted into the clot to carefully pull the clot out of the artery. The Penumbra Device is a suction device that is applied to the clot to carefully remove it.
The INI Stroke Center has highly trained neuro-interventional radiologists who specialize in providing these treatment options. As with other treatment options, the physician team will work closely with the patient and the patient’s family to discuss which treatment options are best for the patient’s condition.