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Q. How to prevent the recurrence of hemorrhagic stroke?

Answered by
Dr. Hitesh Kumar
and medically reviewed by Dr. K Shobana
This is a premium question & answer published on Oct 16, 2021

Hello doctor,

My 72-year-old father had numbness in the left side of his body with palsy in the left corner of his mouth. We went to the emergency, and his BP was 130/78 mmHg. He was admitted for one week and was given antihypertensive and antidiabetic. When he was in the hospital, he developed right-hand cellulitis and was given antibiotics.

It is two weeks now since he was discharged. His condition improved. He is mentally very healthy nothing has changed since his hemorrhagic stroke. He can walk and sit without help. And also, there is no numbness, and his face and mouth look normal now.

Before his stroke, he had been taking low-dose Aspirin for a long time. Kindly review his brain images and read the report. I would like to know everything about his condition.

What is small artery disease? Is it dangerous? Can it be prevented?

Thanks.

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Hello,

Welcome to icliniq.com.

The attached images show hemorrhage in the right basal ganglia region (attachments removed to protect the patient’s identity). Hemorrhage in this area is commonly due to high BP (blood pressure). As per your description, he had a BP of 130/78 mmHg at the time of the emergency room visit. Sometimes there can be an intermittent increase in BP, and occasionally such bleeding can happen due to other causes like vasculitis, amyloid angiopathy, ventricular malformation, etc.

As you mentioned, he is better than before; it is a good sign of recovery from hemorrhagic stroke. To prevent such episodes from happening again, the patient should keep his BP under control and monitor his BP regularly at home. For better recovery from stroke, he can try physiotherapy under the guidance of a physiotherapist. There are no such medical guidelines, such as every person above 65 years should take aspirin. It depends on the underlying risk factors and medical conditions of the patient.

Small artery disease commonly signifies vasculitis involving small blood vessels.

Please elaborate on your query in detail about small vessel disease.

Regards.


Preventive measures:

Physiotherapy.

Hello doctor,

Thanks for the reply.

In his CT report, it was mentioned that he has small artery disease. What does it mean? Is it dangerous? When will the blood in his brain go away?

He chokes during drinking and eating. Is there a cure for his choking problem?

Thanks.

#

Hello,

Welcome back to icliniq.com.

In CT (computed tomography) report, a line states that exaggerated bilateral sheets of hypodensities seen at the periventricular region likely chronic white matter ischemia or small vessel disease. Possibly it is because the radiologist has seen some hypodensities (blackish area in CT) around brain ventricles (ventricles are central structures of the brain), which are not visible in photographs.

Such hypodensities seem chronic white matter ischemia, which are common in patients having risk factors of diabetes, hypertension, heart problem, and also in smokers. This means there is prolonged standing blockage of small blood vessels supplying blood to these central brain areas and may cause such changes in CT in the long term. These changes are better visualized in MRI (magnetic resonance imaging).

These are not dangerous, but they can cause forgetfulness or gait balancing disturbance in some patients if they involve a large area.

The choking problem may be related to stroke. For that, I would suggest consulting a neurologist and ENT specialist. Blood in the brain after a hemorrhagic stroke takes few weeks to months to disappear.

Take care.

Thank you doctor,

We had MRI. This is the result. There is a mild irregularity of vessels along the circle of Willis in keeping with mild atherosclerotic changes. There is no significant stenosis or occlusion in major vessels. There is hypoplastic right A1 segment, right vertebral artery, and fetal right PCA. There is no definite vascular malformation or aneurysmal dilatation along the circle of Willis. The impression shows mild atherosclerotic changes along the circle of Willis. The following findings are seen. Abnormal signal intensity is seen in the right basal ganglia with mild perilesional edema. It shows high signal intensity on all pulse sequences with a low signal intensity rim on T2-weighted images. The appearances are likely due to a small subacute hematoma in the right basal ganglia.

There are multiple small scattered areas of old ischemic infarctions in the basal ganglia, thalami, posterior limb of the internal capsule, and adjacent external capsule, pons with faint changes in the cerebellar hemisphere. There are prominent Virchow robin spaces in the basal ganglia likely in keeping with underlying neurodegeneration. There are significant microvascular ischemic changes in the white matter associated with chronic lacunar infarcts in the periventricular region.

There is no definite intracerebral mass. Ventricles and cortical sulci show age-related involution. There is a compressed pituitary gland in keeping with empty sella turcica. Bilateral cavernous sinus are shown. Both vestibulocochlear nerve complexes are intact. There is a subtle irregularity in the right cavernous carotid likely due to atherosclerotic changes. There is no midline shift seen. Chronic mastoiditis is seen. Mucosal disease in the paranasal sinuses with polypoid changes in the right maxillary, the possibility of superimposed fungal colonization cannot be entirely excluded.

The MRA circle of Willis exam shows mild irregularity of vessels along the circle of Willis in keeping with mild atherosclerotic changes. There is no significant stenosis or occlusion in major vessels. Hypoplastic right A1 segment, right vertebral artery, Fetal right PCA is also seen. There is no definite vascular malformation or aneurysmal dilatation along the circle of Willis.

The impression shows a small subacute hematoma in the right basal ganglia. Significant microvascular ischemic changes in the white matter with multiple old ischemic infarctions showing lacunar infarcts with neurodegeneration as detailed above. There is no intracerebral mass and empty sella turcica. There is a mucosal disease in the paranasal sinuses and mild atherosclerotic changes along the circle of Willis.

#

Hi,

Welcome back to icliniq.com.

The MRI also shows a small bleeding area in the right basal ganglia (which was also visible in CT Head). The significant microvascular ischemic changes in the white matter with multiple old ischemic infarctions showing lacunar infarcts are the same microvascular changes, which were seen in CT as exaggerated bilateral sheets of hypo densities seen at the periventricular region likely chronic white matter ischemia or small vessel disease. These are found in many patients with risk factors such as old age, diabetes, hypertension, smoking. Continue physiotherapy and medications as suggested. Keep monitoring blood pressure.

Thank you doctor,

Is there anything serious in the white matter? What is the risk of having it? Is there anything to do to lower his blood pressure? Even after taking medications, it is still at 135 to 145 mmHg.

#

Hi,

Welcome back to icliniq.com.

With the history given by you in query, white matter changes are not serious. In long term, patients having white matter changes have more tendency to develop forgetfulness, memory impairment, ischemic stroke and walking difficulty. But prediction cannot be done if such will happen in any particular patient or not. For lowering blood pressure, I would suggest meeting the treating doctor to modify his BP (blood pressure) medications to control his blood pressure.


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