Favourable Conditions in Stroke Management: Saving Lives from Haemorrhagic Stroke

To recap, ischaemic strokes account for 70% of stroke cases, caused by cerebral vascular occlusion. The optimal treatment is to administer medication or perform minimally invasive catheter procedures within the critical golden hour to reopen the blocked vessel and save the brain cells at risk of dying due to lack of blood flow.

In contrast, haemorrhagic strokes, which comprise 30% of stroke cases, result from a ruptured blood vessel in the brain. The extravasated blood causes a sudden increase in intracranial pressure, both locally and diffusely, leading to direct damage and necrosis of brain cells due to the compressive force of the haematoma. Emergency treatment involves using medication, minimally invasive drainage, or craniotomy to remove the blood or excess cerebrospinal fluid, thereby reducing intracranial pressure and saving brain cells threatened by compression.

Arteriovenous Malformation (AVM)

Cerebral Aneurysm

Primary Causes of Haemorrhagic Stroke

Haemorrhagic strokes, caused by blood vessel rupture, usually result from congenital or acquired cerebrovascular abnormalities, including:

Arteriovenous Malformation (AVM)

AVM is a congenital condition, affecting patients of all ages, from children as young as four to adults over 80 years old.

Cerebral Aneurysm

A cerebral aneurysm rupture, commonly referred to as a ‘burst blood vessel stroke,’ can cause a subarachnoid haemorrhage (SAH), which is an acquired condition. Patients' ages range from 28 to over 100 years, and it generally has no direct association with hypertension.

Rupture of Cerebral Microvessels

The well-known "three highs" (high cholesterol, high blood pressure, high blood sugar) can weaken cerebral microvessels, making them prone to rupture. This is one of the most common causes of haemorrhagic stroke.

As previously mentioned, a comprehensive and objective physical examination, including 3D imaging of the carotid and cerebral vessels, is the most effective method for screening potential stroke risks. The prognosis and management of haemorrhagic strokes, like ischaemic strokes, depend heavily on the timely and effective integration of favourable circumstances.

As commonly described, the symptoms and severity of haemorrhagic strokes tend to be more rapid and severe compared to ischaemic strokes. Patients often present with headaches, and at the onset, besides potential speech and facial impairments, and limb weakness, the sudden rise in intracranial pressure may cause rapid deterioration in the patient’s condition, leading to loss of consciousness or deep coma.

Real-life Case Studies

The following case studies highlight the critical importance of timely and coordinated stroke management in haemorrhagic stroke emergencies.

Case 1: Miss Yeung, Aged 29 at the Time of Stroke

Fourteen years ago, Miss Yeung, then 29 years old, was healthy and led a normal life with no history of headaches. Three days after her wedding, her husband returned home to find her unconscious on the floor and immediately called an ambulance. A brain CT scan at the nearby public hospital revealed subarachnoid haemorrhage (see Figure 1), suspected to be caused by a ruptured cerebral aneurysm. As the hospital lacked neurosurgical services, her husband requested a transfer to a private hospital.

Dynamic 3D angiography confirmed a ruptured aneurysm in the left posterior communicating artery, necessitating an urgent minimally invasive endovascular procedure. A neurosurgeon successfully coiled the aneurysm (see Figure 2), preventing further bleeding and reducing intracranial pressure with medication. Fortunately, the haemorrhage did not cause severe brain damage, and Miss Yeung regained consciousness two days after the procedure. She was discharged after three weeks of recovery.

Three months later, a stent-assisted coiling procedure was performed to completely obliterate the remaining aneurysm (see Figure 3), ensuring no residual risk. Miss Yeung has since made a full recovery with no further complications.

Case 2: Mr Lee, Aged 39 at the Time of Stroke

Three years ago, Mr Lee, a 39-year-old construction worker and the primary breadwinner for his family, suddenly experienced a severe headache on-site, followed by collapse. His colleagues called an ambulance, and he was admitted to a nearby public hospital, semi-conscious upon arrival.

A brain CT scan revealed subarachnoid haemorrhage (see Figure 4). Angiography showed a 1-2mm aneurysm in the anterior communicating artery (see Figure 5).

Unfortunately, Mr Lee fell into a deep coma the next morning. A subsequent CT scan revealed a second rupture of the aneurysm, causing severe brain haemorrhage and increased intracranial pressure. An emergency craniotomy was performed to evacuate the haematoma and reduce intracranial pressure through ventricular drainage (see Figure 6), while the aneurysm was clipped with a titanium clip (see Figure 7) to prevent further rupture.

Due to brain swelling, his skull could not be replaced immediately, and only the scalp was sutured to accommodate the swollen brain tissue. Although the surgery was technically successful, the second rupture caused severe neurological damage (see Figure 8). For the past three years, Mr Lee has been in a vegetative state, residing in a nursing home.

In addition to ischaemic and haemorrhagic strokes, "transient ischaemic attacks" (TIAs), commonly known as "mini-strokes," serve as early warning signs of potential strokes. Symptoms of TIAs disappear within 24 hours, and they may not be detectable on imaging scans. TIAs are often caused by minor clots that do not fully obstruct blood vessels or cause permanent brain damage. Clinically, 20-25% of patients have experienced a TIA prior to a major stroke. Many do not seek medical attention as the symptoms resolve quickly, missing the opportunity for effective stroke prevention.