Hemorrhagic Stroke

Hemorrhage or hemorrhagic comes from the Greek word to "to burst forth with blood." A hemorrhagic stroke occurs when there is bleeding in the brain due to a disease of brain blood vessels or a clotting abnormality.

Arteries and other small blood vessels create pathways throughout the brain that bring blood from the heart. If these arteries or blood vessels are abnormally formed, they may weaken and burst, and can cause a hemorrhagic stroke.

The blood carries oxygen and other important nutrients to the brain and the brain needs oxygen to survive. If a part of the brain does not receive oxygen from the blood for a certain period of time, the tissue in that part of the brain will die. Bleeding into the brain from a hemorrhagic stroke interrupts the normal blood flow through the arteries and causes direct damage to tissue in that area of the brain.

Causes

There are several possible causes of hemorrhagic stroke:

• Aneurysm: Some blood vessels have a weakened area where the blood causes the wall to "balloon." If this ballooning is left untreated, it may continue to weaken, burst and bleed into the brain.
• Arteriovenous malformation (AVM): An AVM is a tangled group of abnormally formed blood vessels. Sometimes one of these vessels can burst and bleed into the brain.
• Damaged or fragile blood vessels: Some children have blood vessels in their brains that are fragile or damaged due to other illnesses. If these blood vessels leak or burst, brain injury can occur.
• Clotting abnormality: Defects of the clotting system causing an increased bleeding tendency, such as hemophilia.

Many children are born with the blood vessel problems that can lead to hemorrhagic stroke. Other children may have other diseases which can contribute to hemorrhagic stroke, including blood clotting disorders, Moyamoya disease, trauma or infection.

Signs and symptoms

In children

Children and teenagers may have one or more symptoms when they are having a hemorrhagic stroke. Typically these symptoms occur suddenly. Initial symptoms may include:

• Severe headache especially with vomiting and sleepiness
• New appearance of seizures, especially if they affect one side of the body and are followed by paralysis on the side of the seizure activity
• Loss of consciousness after one or more of the above symptoms

• Weakness or numbness of the face, arm or leg, usually on one side of the body
• Trouble walking due to weakness or trouble moving one side of the body
• Problems speaking or understanding language, including slurred speech, trouble trying to speak, inability to speak at all, or difficulty in understanding simple directions
• Trouble seeing clearly in one or both eyes
• Severe dizziness or unsteadiness that may lead to losing balance or falling

In newborns and infants

• Seizures
• Extreme irritability
• Vomiting
• Bulging fontanelle (soft spot on top of the baby's head)
• Loss of consciousness

What you can do

If your child has any of the signs or symptoms associated with a stroke:

• Dial 911 or go to your nearest hospital Emergency Department
• Have your child lie flat
• Do not give your child anything to eat or drink
• Suggest that your local medical professional contact the CHOP Stroke team for consultation. They may contact the CHOP operator at 215-590-1000 and ask for the Stroke team to be paged

Testing and diagnosis

The Stroke team will want to find out as much information as possible to diagnose your child's stroke and the reasons why the stroke occurred.

Physical exam

The Stroke team will perform a thorough physical exam including a neurological exam to gain more information about how your child's brain is currently working.

Blood work

The Stroke team will request that blood tests be done to test to see if your child has any underlying blood problems that could cause bleeding.

Imaging

The Stroke team will request that various types of tests be done that will give a better picture or "image" of your child's brain. These tests may include computed tomography (CT) scans, magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) or cerebral angiogram (also called an arteriogram). If the Stroke team feels more information about your child's heart may be useful, they may order an echocardiogram.

Other tests

Depending on your child's symptoms, the Stroke Program team may feel a need to order some other tests. These may include a lumbar puncture (LP) also known as a "spinal tap" to look for signs of infection or inflammation that may have caused the stroke.

Treatment

Hemorrhagic stroke often requires emergency treatment. Once initial testing is completed, the Stroke team will consult with the Neurosurgery team and Interventional Radiology team to determine if further treatment is needed. In some cases, procedures may be needed to repair the aneurysm or remove the AVM. These procedures may include:

• Surgical intervention. A neurosurgeon may place a metal clip at the base of the aneurysm or remove the abnormal vessels of the AVM.
• Endovascular procedures. An interventional radiologist may guide a special wired instrument called a catheter through an artery in the upper part of the child's leg up to the area where the ruptured aneurysm or AVM is located. Then a metal coil is placed there to prevent further damage from leaking blood.

Outlook and long-term care

How much the stroke will affect your child's day-to-day life depends on the location and severity of the stroke. Some strokes cause mild problems. Some cause more severe problems. Some children may continue to have seizures.

Your child's Stroke team will consult with the Rehabilitation team for advice on how best to help your child recover. Rehabilitation is a structured series of exercises to help your child recover from the effects of the stroke. Therapy usually begins within 48 hours of admission, provided your child is medically stable and is able to tolerate these activities. Members of the Rehabilitation team may include a physical therapist (PT), occupational therapist (OT), speech therapist, neuropsychologist and physiatrist ("Rehab" or "PM &R" Physician).

Depending on the results of their assessments, it may be recommended that your child have further rehabilitation. This rehabilitation could range from a stay in the inpatient rehabilitation unit, to Day Hospital rehabilitation, to outpatient rehabilitation appointments. Rehabilitation may last from weeks to months depending on your child's needs.

It's important to keep in mind that children recover more quickly from a stroke as compared to adults. Members of the Stroke Program team and the Rehabilitation team will continue to assist you and your child in the recovery process and help your child return to a more normal lifestyle as soon as possible. If your child is school age, we will work with your child's school to recommend any needed changes to your child's curriculum and school day.