Friday, March 9, 2012

Bleed Vs. Block: Who Can Expect Better Recovery?

       Survivors who have a hemorrhagic (bleed) stroke average better recovery than survivors who have an ischemic (block) stroke. But bleed strokes usually have more disability to begin with. In other words, “bleeds”  start out lower but end up higher. The difference has to do with the different ways these types of stroke affect neurons:

“Block” stroke: neurons die because blood flow is blocked. No blood, no O2.   No O2, neurons die.
“Bleed” stroke: much of the damage comes from the compression on the brain by the buildup of blood in the skull. Once the compression is resolved there is less overall neuronal damage.

Bottom line: The effect of efforts towards recovery can be expected to be less for ischemic vs. hemorrhagic stroke. Rehab strategies that work well for bleed stroke will typically have less rehab potential for survivors with a block stroke.

This is one of my problems with books about survivors who've had a bleed stroke.  Some of the  books give the impression that they a) had more will, b) are smarter, c) have come up with a new and special technique. Again, on average, they start out lower but end up higher. So the recovery process is scary and arduous, but ultimately more fruitful. And it is more fruitful because there is less brain damage. 

Of course, the prime example of this fudging of the facts is Jill Bolte-Taylor's book My Stroke of Insight.  She had a bleed stroke on the left side of the brain.  Have a look at this video. Does anyone see any deficit in either the right arm/hand or in her speech?

Almost 90% of all stroke are blocks, not bleeds.

Want the science-y perspective?

"If 2 patients at the beginning of rehabilitation had the same basal neurological severity, same basal functional disability, same age, same sex, and same OAI, hemorrhagic patients showed better neurological and functional prognosis compared with ischemic ones."

And to be clear: Bleed strokes are terrible. You have a greater chance of dying from a bleed than a block. And recovery from any stroke is to be celebrated. 

But beware of inflated expectations suggestions by survivors of a bleed stroke. What they suggest may work for them but it is clear: their recovery will usually be higher given the same amount of effort.



Sara G said...

I'm 2 1/2 years out from a bleed and have a long ways to go. Every recovery is different. I have limited feeling and function on right side, walking/balance issues and well, I'm just happy to be alive. I guess I don't see how my recovery is better. Of course I can only go by my own experience and the few friends that I know. In my opinion it's never good to compare but as humans, we have been trained to compare.

oc1dean said...

Pete, Is there any public place that these statistics are available? I'm working on an opinion piece for the NYT and finding information is like trying to recover from a stroke.

Peter G Levine said...

Dean, what are the particular statistics you looking for? Maybe I can help you find them? Also, define "public". Would that include peer-reviewed journal articles available on pub med? Feel free to e-mail me. Thanks Dean

Peter G Levine said...

Sarah, every recovery IS different. My blog entry wasn't to suggest that recovering from bleed is easy. But the arc of recovery can be much more dramatic because, again, bleed strokes start out lower but end up higher. And it would be a bit more forthcoming from folks to write books about recovery from bleeding strokes to say, at some point in the book, "Outcomes may be very well much lower for 90% of all stroke survivors".

I wish you the best. Thank you.

Elizabeth, John and Jack said...

I'm not so sure about this. Mine was a result of a severed blood vessel during brain surgery. They classified it as an "ischemic" stroke,although it wasn't really a block or a bleed. I just consider myself VERY LUCKY. While I'm not 100% recovery has been "easier" than many others. It has been/ continues to be plenty hard, but for the physical was pretty straight the exercises like crazy, get better. Not so much for the cognitive issues or the fatigue, but I just keep at it, and always expect improvement. If they knew why some people recover easier than could be a huge turning point in stroke recovery. I'm guessing there a lot to it: age, general health prior to the stroke, location, size of the stroke, attitude...on and on.

Kadima said...

Thanks for explaining this. We've worked so hard since my wife's ischemic stroke last March but with modest results. Most of the books I've read show much better improvement but they all referred to bleeding strokes.

Edwina said...

Hi all,
Don't give up those who have suffered ischemic strokes. My brother-in-law, 47, suffered a serious ischemic left hemisphere stroke in Oct 2011. It killed off a large percentage of his left hemisphere....we had no idea what to expect when he awoke. When he did he was totally paralysed on his right side, had lost all speech, couldn't read and couldn't understand a lot, indeed he was closer to death than life for a few days at least. He had an operation to remove a large portion of his skull to ease swelling. It was what saved his life.
Now, nearly six months on...he is walking and going for 6 kilometre walks alone. He goes to his gym and works on the machines. His right arm is very functional, however his hand is only able to squeeze yours and sometimes he has trouble letting go! Speech is still not good, however improving and much clearer, he can copy a lot of speech, but still has trouble initiating speech on his own. He was a super-fit 47 yo male who ran regularly and rowed regularly. He also always pushed himself to try harder in everything he did. I'm sure we have not seen the end of his improvement.

T.Julian said...

My daughter is having all kind of problems after her stroke at 11 years old. One is she blacks out frequently, she can hear but not see for 15-20 sec.. She just had her first dream since this happened four years ago, yesterday, but she hasn't been feeling well lately. Somethings changing don't know if for better or worse.

Tamara said...

Glad to read that bleeds have a better chance. My subarachnoid hemorrhage is 3 years ago and I'm still working hard to recover. The emotional
side is the hardest part for me. I feel anxious most of the time and that increases my spasms. I'm from Holland and fortunately a lot of therapies are covered by insurance here, but therapists tend to discourage me by saying my expectations for recovery are to high. A few weeks ago I went back to a rehabilitation center, also to work on my left arm and hand, but I'm not sure on what to work at, task specific wise. Before my brain exploded I only used my left hand to type, to hold my fork and put my hair up. I suggested to my OT to start working on my hand by doing games like checkers with my left arm, but my OT didn't agree and said that I would get better at moving checker pieces across the board with my left hand, while I see it as a variation of the pegboard mentioned in the book Stronger after Stroke. She also said she doesn't want to get my hopes up and that I expect to much of recovery. So I try to use my left arm and hand at home as much as I can, for instance by holding a jar in my left hand and opening it with my right and switching the light on and off with left.

Mickie Yezek Roller said...

A had a stroke; I believe it's mercury fillings. I was hypotensive, dehydrated, lethargic and weak. I was on a monitor bed with a catheter, IV's and a shockingly low blood pressure at 63/28. It's 1999. Not good.
Read my website,

Tamara said...

A few doctors and therapists told me that neuroplasticity doesn't always happen. I wonder if they say that, so I don't get too much hope for recovery or if this is really true. I guess it doesn't happen when you don't try enough or when you are really old and have lots of other health problems, maybe dementia kicking in.
I'm really thankful for this blog by the way!

Caprizzosa said...

Hi there,
Could I ask you what you mean when you say they start low but finish high?
My husband had a stroke 7 months ago. he is walking with a limp and although he has feeling and movement in his arm and fingers (not wrist yet) he has no control movement. Can you help?

Caprizzosa said...

HI, Can you explain further what you mean with starting low and finishing high?
My husband had a hemorrhagic stroke 7 months ago.
he is able to walk with a limo and he has movement and strength in his arm and some finger movement, no wrist yet or at least very little. I still hope he will make a good recovery as we have two little boys.
Can you tell me id you thinks there is a link between the speed at what the person recovers and the speed at which the hematoma cleans up?
Thank you!!

Peter G Levine said...

Hi Caprizzosa,
"Start out lower but end up higher." means that TYPICALLY bleeds will get more recovery of movement than blocks. TYPICALLY. So the outcome is individual, case by case, and can have wide variability. I'm also pretty sure that I've read somewhere that the arc of recovery is longer for bleeds than blocks. So while most recovery for a block may be in the 1st 3 months (TYPICALLY) for a bleed stroke that window is longer (say, 4-10 months). Any more Q's and feel free to email me at

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