PREVENTION of BRAIN BLEEDS
If a gross blood vessel abnormality such as aneurysm or arteriovenous malformation was found or a brain mass lesion such as cancer was detected or a general bleeding tendency diagnosed with appropriate testing, these conditions would indeed need to be managed in light of best practice guidelines by appropriate physicians to decrease the future risk of brain bleeds. Most patients at high risk of brain bleeding do not have any of these features though, so treating risk factors become very important for prevention.
Two major categories of risk factors are important to know about for optimal prevention of brain bleeds. The first one include the correction of risk factors and treating medical conditions that can cause brain bleeds. The second category is the broad issue of blood thinner use, an important treatment modality for "ischemic" conditions that unfortunately increase the risk of brain bleeds. This second category will be discussed in greater detail under "RISKS of BLOOD THINNERS & ALTERNATIVES" section of this website.
1) The modifiable risk factors that should be controlled with medical and/or behavioral interventions when needed include:
- high blood pressure: the single most common and important risk factor for all hemorrhagic strokes as well as ischemic strokes and heart attacks. Careful monitoring and control of hypertension is important to decrease the risk of all cardiovascular events. Individual blood pressure targets should be discussed with the treating physician and appropriate measures should be taken to achieve these goals
- smoking is a well-established risk factor not only for hemorrhagic stroke but also for ischemic stroke, heart attack, peripheral arterial disease, lung disease and multiple cancers. Smoking should be stopped and professional help should be requested, if needed, for smoking cessation
- moderate to heavy alcohol use is a well-established risk factor for hemorrhagic and ischemic strokes. Alcohol even at low doses has several effects that decrease platelet function therefore making it difficult for the coagulation system to stop bleeding should one occur. Higher doses can also damage the liver and further decrease coagulation pathways even when they are needed. A safe level of alcohol intake is not established in patients who have relatively high brain bleeding risk. For this reason, stopping alcohol intake altogether might cut down the risk of brain bleeding by several points in patients at relatively high risk
- cocaine and methamphetamine are known causes of brain bleeds as well as many other poor health outcomes
- previous ischemic stroke is an independent risk factor for ICH, so controlling diabetes and obesity and maintaining a healthy lifestyle with good exercise and sleep habits are other reasonable preventive strategies
2) Better understanding the risk/benefits of medications that increase the risk of brain bleeds in individual patients and considering non-pharmacological alternatives can allow optimal risk management
- Blood thinner use in patients at higher than usual brain bleeding risk is a double edged sword. Different blood thinners have established benefits in specific diseases, atherosclerosis, atrial fibrillation and deep venous thrombosis being the most common ones. On the other hand, especially the stronger category called anticoagulants increase the risk of brain bleeds. The severity of brain bleeds happening while on anticoagulants are even worse than non-anticoagulant related brain hemorrhages. A good understanding of the ischemic and hemorrhagic risk in the individual patient and considering FDA-approved non-medication alternatives if available are important approaches. These issues will be discussed in detail under "RISKS of BLOOD THINNERS & ALTERNATIVES" section of this website.
- Whether statins and SSRIs increase the risk of hemorrhagic stroke is NOT well-established. These medications should be used in accordance with established guidelines for FDA-approved indications