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What Causes Exhaustion And Disturbed Sleep When Diagnosed With Hemorrhagic Stroke?
Question: My 45 year old sister had a hemorrhagic stroke two weeks ago. No cause has been found. Her cognition is good and her speech is quite good but has word finding difficulties. She has been so exhausted and medically unwell due to bowel issues and very, VERY little sleep that she is having great difficulty with her rehab. She is not depressed but refused physio today due to exhaustion. We have seen movement in her leg (that she is unaware of) and today she was able to push away a bit with her leg when it was in a 90 degree position. Her arm and hand have done nothing yet but she does have feeling in them. Do we have reason to hope for some degree of mobility? She has an 8 year old and a 10 year old who need her badly!!
Brief Answer:
Improvement is expected
Detailed Answer:
I read your question carefully and I am really sorry about what has happened to your sister, I know how traumatic and life-changing a stroke can be, for all the family.
I do not know the exact location and size of the hemorrhage but symptoms such as fatigue, normal sleep wake cycle disruption, bowel movement alteration etc are to be expected especially in this early period.
But regarding your question on whether any degree of movement is expected the answer is positive, improvement is certainly expected. Improvement after stroke goes on for many months, up to six months, thanks to the unaffected areas assuming some of the functions previously belonging to the damaged ones (an ability of brain cells which is called plasticity). If it's been only two weeks it's two early to judge yet, if it was a big hemorrhage it may not even be absorbed yet, after two weeks there usually is still some blood left as well as edema, swelling causing mass effect and compressing still living brain cells. So once all the blood is absorbed and the edema subsided, with the plasticity I was speaking about taking gradually place improvement is expected over several months.
The degree varies from the location of the damaged area and its size. It also varies among different persons, exact predictions can't be made, but in a young subject, only 45 years old there is reason to be optimistic. I have had many patients leaving in a bed and coming back to follow-up consults months later on their feet, perhaps aided by a cane, but still unrecognizable from when they left the hospital. Of course physical therapy is a very important part of that process.
I remain at your disposal for further questions.
Improvement is expected
Detailed Answer:
I read your question carefully and I am really sorry about what has happened to your sister, I know how traumatic and life-changing a stroke can be, for all the family.
I do not know the exact location and size of the hemorrhage but symptoms such as fatigue, normal sleep wake cycle disruption, bowel movement alteration etc are to be expected especially in this early period.
But regarding your question on whether any degree of movement is expected the answer is positive, improvement is certainly expected. Improvement after stroke goes on for many months, up to six months, thanks to the unaffected areas assuming some of the functions previously belonging to the damaged ones (an ability of brain cells which is called plasticity). If it's been only two weeks it's two early to judge yet, if it was a big hemorrhage it may not even be absorbed yet, after two weeks there usually is still some blood left as well as edema, swelling causing mass effect and compressing still living brain cells. So once all the blood is absorbed and the edema subsided, with the plasticity I was speaking about taking gradually place improvement is expected over several months.
The degree varies from the location of the damaged area and its size. It also varies among different persons, exact predictions can't be made, but in a young subject, only 45 years old there is reason to be optimistic. I have had many patients leaving in a bed and coming back to follow-up consults months later on their feet, perhaps aided by a cane, but still unrecognizable from when they left the hospital. Of course physical therapy is a very important part of that process.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
She is taking Baclavan for muscle spasms but I looked it up and it says that stroke patients shouldn't take that because of the type of side effects. Tiredness, muscle weakness etc.. She seems to only have spasms in her arm when something else is hurting - bowels etc. Is there something else that can be taken?
Her hemorrhage was apparently very large so I am assuming that there is still blood absorption taking place. She doesn't have a follow-up MRI until October 19th.
Another point is that she had the stroke one day before the start of her menstrual cycle. She has been having terrible PMS for the last year or so - bad headaches, extreme bloating. She is scared that something else will happen when her cycle begins again and wonders if this could have caused the stroke (obviously only if there was something else going on as well).
My sister had a confirmed case of Lyme's disease about 7 years ago. Would this potentially do damage to blood vessels?
At this point I am trying to uncover the reason so that we can try to make sure that this doesn't happen again. She is only scheduled to go back to the neurologist at about the 3 month mark.
Any other insight you have would be welcome. Thank you.
Her hemorrhage was apparently very large so I am assuming that there is still blood absorption taking place. She doesn't have a follow-up MRI until October 19th.
Another point is that she had the stroke one day before the start of her menstrual cycle. She has been having terrible PMS for the last year or so - bad headaches, extreme bloating. She is scared that something else will happen when her cycle begins again and wonders if this could have caused the stroke (obviously only if there was something else going on as well).
My sister had a confirmed case of Lyme's disease about 7 years ago. Would this potentially do damage to blood vessels?
At this point I am trying to uncover the reason so that we can try to make sure that this doesn't happen again. She is only scheduled to go back to the neurologist at about the 3 month mark.
Any other insight you have would be welcome. Thank you.
Brief Answer:
Read below
Detailed Answer:
Thank you for the update.
Baclofen, it's not about spasms, but spasticity which is a different thing, means increased muscle tonicity (constant, not in the form of spasms), which is observed on passive movement of the limb, or noticed by limbs keeping a certain abnormal position. Like most drugs it may have side effects, but when there is marked spasticity which makes physical therapy difficult, leads to joint arthrosis and pain it is used. Whether I agree with its use in your sister's case....I do not use it routinely in stroke patients and generally spasticity develops later then the first few weeks, but it's not something clear cut, it is more marked more early in some patients, so if it's something obvious to the neurologist or physical therapist during exercises it may be used. Alternative is benzodiazepines drugs. But as I said if no marked spasticity I don't use medication for it routinely, physical therapy is more important.
Menstrual cycle is not the cause, you and your sister should not worry about that. Lyme disease, while it can at times involve the central nervous system, doesn't cause such massive hemorrhages, involves other structures with different manifestations and not acute onset.
Most common causes of hemorrhage are either long standing high blood pressure or malformations of blood vessels in the brain. The follow-up imaging is done to search for the presence of malformations. It is not uncommon for such malformations not to found during the first few weeks because the blood and swelling distortion obstruct the view. So three months when the acute changes have by then completely subsided is the correct time to have the exam, you shouldn't ask doctors for earlier time, have to be patient. In case you are afraid it might bleed again that risk is very low do not worry. As an example for the most common cause, arteriovenous malformations the risk of rebleed is about 4% per year, so for 3 months only 1%. So while they should be searched for, should be done in the right time frames as the aim is to avoid the long term rebleed risk, short term risk is very low.
If that follow-up exam results normal as well then whether to be pushed further with an invasive exam like angiography will have to be considered. That decision will depend on whether there is evidence of high blood pressure and hemorrhage location. When there is such history of blood pressure in the past and the location of the hemorrhage is typical it may be left at that, with hypertension as a cause, otherwise an angiography may be done.
I hope to have been of help
Read below
Detailed Answer:
Thank you for the update.
Baclofen, it's not about spasms, but spasticity which is a different thing, means increased muscle tonicity (constant, not in the form of spasms), which is observed on passive movement of the limb, or noticed by limbs keeping a certain abnormal position. Like most drugs it may have side effects, but when there is marked spasticity which makes physical therapy difficult, leads to joint arthrosis and pain it is used. Whether I agree with its use in your sister's case....I do not use it routinely in stroke patients and generally spasticity develops later then the first few weeks, but it's not something clear cut, it is more marked more early in some patients, so if it's something obvious to the neurologist or physical therapist during exercises it may be used. Alternative is benzodiazepines drugs. But as I said if no marked spasticity I don't use medication for it routinely, physical therapy is more important.
Menstrual cycle is not the cause, you and your sister should not worry about that. Lyme disease, while it can at times involve the central nervous system, doesn't cause such massive hemorrhages, involves other structures with different manifestations and not acute onset.
Most common causes of hemorrhage are either long standing high blood pressure or malformations of blood vessels in the brain. The follow-up imaging is done to search for the presence of malformations. It is not uncommon for such malformations not to found during the first few weeks because the blood and swelling distortion obstruct the view. So three months when the acute changes have by then completely subsided is the correct time to have the exam, you shouldn't ask doctors for earlier time, have to be patient. In case you are afraid it might bleed again that risk is very low do not worry. As an example for the most common cause, arteriovenous malformations the risk of rebleed is about 4% per year, so for 3 months only 1%. So while they should be searched for, should be done in the right time frames as the aim is to avoid the long term rebleed risk, short term risk is very low.
If that follow-up exam results normal as well then whether to be pushed further with an invasive exam like angiography will have to be considered. That decision will depend on whether there is evidence of high blood pressure and hemorrhage location. When there is such history of blood pressure in the past and the location of the hemorrhage is typical it may be left at that, with hypertension as a cause, otherwise an angiography may be done.
I hope to have been of help
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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