Treatment includes life-saving measures, relief of symptoms, repair of the cause of the bleeding, prevention of complications, and start of rehabilitation as soon as possible. Recovery may occur over time as other areas of the brain take over functioning for the damaged areas.
IMMEDIATE TREATMENT
Treatment is ideally administered in an intensive care unit, where complications can immediately be detected. Medical personnel pay careful attention to breathing because sometimes persons with brain hemorrhage develop very irregular breathing patterns or even stop breathing entirely.
A person having a hemorrhagic stroke may be unable to protect the airway during coughing or sneezing because of impaired consciousness. Saliva or other secretions may go "down the wrong pipe," which is potentially serious and may cause lung problems such as aspiration pneumonia. In order to treat and/or prevent these breathing problems, a tube may need to be placed through the mouth into the trachea to initiate mechanical ventilation.
The blood pressure may be too high or too low in patients with brain hemorrhage. These problems need to be addressed immediately by doctors. In addition, brain bleeding may cause swelling of surrounding brain tissue, and this may require therapy with some drugs called hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions).
Bedrest may be advised to avoid increasing the pressure in the head (intracranial pressure). This may include avoiding activities such as bending over, straining, lying flat, sudden position changes or similar activities. Stool softeners or laxatives may prevent straining during bowel excretion (straining also causes increased intracranial pressure).
Analgesics and antianxiety medications may relieve headache but should be used with caution because they may reduce consciousness and this may produce the wrong impression that the patient is getting worse. Antihypertensive medications may be prescribed to moderately reduce high blood pressure. Medications such as phenytoin may be needed to prevent or treat seizures.
Nutrients and fluids may need to be supplemented if swallowing difficulties are present. This can be intravenous or through a feeding tube into the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.
Positioning, range-of-motion exercises, speech therapy, occupational therapy, physical therapy, and other interventions may be advised to prevent complications and promote maximum recovery of function.
SURGICAL TREATMENT
Sometimes, surgical interventions are needed to save the life of patients or to improve their chances of meaningful recovery. The type of surgery depends upon the specific cause of brain bleeding.
The goal of surgery for subarachnoid bleeding, for example, is to suppress the chances of a second bleed from any identified aneurysm, which would almost always be fatal. The surgeon has to open up the skin and skull to expose the base of the brain, where the aneurysm is located, and place a clip on it, which prevents future leaking of blood from the affected artery. When surgery is too risky or technically impossible, a coil embolization can be attempted. This procedure consists of threading a special coil into the aneurysm through a catheter inserted in an artery. The coil literally clogs the aneurysm, preventing further leakage of blood.
For other types bleeding, a removal of the hematoma may occasionally be needed, especially when bleeding occurs in the back of the brain. Some physicians are currently investigating whether the injection of a "clot buster" inside the hematoma can facilitate the removal of brain hemorrhages through needles or catheters, therefore allowing less invasive surgery.
One common problem related to brain bleeding is hydrocephalus, which is the accumulation of a water-like fluid within the brain cavities called ventricles. To solve this problem, the fluid may need to be drained with a special procedure called ventriculostomy.
For AVM, different treatments are available, including surgical removal of the AVM network, radiosurgery (using ionizing radiation to reduce the size of the AVM), and intra-arterial embolization ( a procedure in which glue is injected into the AVM to close the connection between arteries and veins).
LONG-TERM TREATMENT
Recovery time and the need for long-term treatment are highly variable in each case. Physical therapy may benefit some persons. Activity should be encouraged within the physical limitations. Alternative forms of communication such as pictures, verbal cues, demonstration or others may be needed depending on the type and extent of language deficit. Speech therapy, occupational therapy, or other interventions may increase the ability of some persons to function.
Urinary catheterization or bladder or bowel control programs may be required to control incontinence.
A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show a marked indifference or lack of judgment, which increases the need for safety precautions.
In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet physiologic needs.
Behavior modification may be helpful for some persons in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation.
Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.
Legal advice may also be appropriate early in the course of the disorder. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of the person with hemorrhagic stroke.
