Hemorrhagic Stroke

A stroke occurs when the normal flow of blood to the brain is interrupted, causing it to be starved of oxygen. If this is caused by a blood vessel bursting in or around the brain, it is known as a hemorrhagic stroke. A stroke is an emergency, and medical attention must be sought immediately. About one in five strokes are hemorrhagic. 1

An acronym, FAST, explains the telltale signs that a stroke is taking place: 2 3

• Face: The face becomes weak or droopy, with the effect usually more visible on one side
• Arm: One arm becomes numb or weak, and there may be difficulty raising it
• Speech: Speaking becomes difficult, and the affected person’s voice becomes slurred
• Time to call: If any of the above is noticed, the emergency services should be called immediately

The severity of the symptoms of a hemorrhagic stroke depends on what parts of the brain are affected.

There are two types of hemorrhagic stroke: 1 2

• An intracerebral hemorrhage (ICH), which is when a blood vessel within the brain ruptures. The main cause of ICHs is high blood pressure. About one in 10 strokes is an ICH.
• [A subarachnoid hemorrhage (SAH),] which is bleeding between the layers of tissue that surround the brain. About one in 20 strokes is an SAH. For more detailed information, see this resource on subarachnoid hemorrhage.

A hemorrhagic stroke is most often diagnosed through a brain scan, such as a CT scan.

Medical treatment in a hospital and close medical supervision is required to guarantee the best possible outcome after a hemorrhagic stroke takes place. Surgery to stop the bleeding or address complications could be necessary. Rehabilitation will very often be useful in dealing with the symptoms that may develop from a hemorrhagic stroke.

The specific symptoms of hemorrhagic stroke vary slightly between intracerebral hemorrhage strokes and subarachnoid hemorrhage strokes. This is because different parts of the brain are usually affected. Sudden weakness, a loss of bodily control and confusion are common to both types of hemorrhagic stroke.

The symptoms of an ICH usually appear suddenly. They include: 3 4

• Numbness or weakness in the face, arm or leg
• Confusion and loss of the ability to speak
• Difficulty seeing or other visual problems due to eye movement difficulties
• A loss of balance and difficulty walking
• Vomiting
• Unusual breathing patterns
• A loss of consciousness and, potentially, a comatose state

The most common symptom is a sudden, explosive headache, called a thunderclap headache, which is often described as the worst headache ever, or as if there had been a blow to the head. It may last only a few seconds or even a fraction of a second. 2

Read more about subarachnoid hemorrhage symptoms »

There are two main types of stroke: hemorrhagic and ischemic, both damaging the brain and therefore very severe conditions. In hemorrhagic stroke, which is the less common of the two, the damage is caused by bleeding in or around the brain. The resulting collection of blood coming out of the bleed begins to put pressure upon and damage the brain tissue surrounding the bleeding site. This initial injury can lead to further swelling and inflammation within the brain, putting it under more pressure. Although a big part of the brain injury from a hemorrhagic stroke occurs because of the initial bleed, continued bleeding and the later swelling can lead to even more complications. That is why it is still so important to get a stroke treated as quickly as possible. 5 6

An ICH stroke occurs when a blood vessel bursts within the brain, causing blood to spill out and damage the area directly affected and, often, surrounding areas. The most common cause of an ICH in adults is hypertension, also known as high blood pressure. This puts extra strain on the blood vessels in your body, including the ones in the brain, making them more likely to burst and bleed.

High blood pressure often shows no specific symptoms, unless it is suddenly rising and/or very severe; this means that many people affected by high blood pressure will not be aware that they have it. 2 This is partly why the symptoms of an ICH can come on without warning and seem so sudden, and why it is also important to get regular medical check-ups that include the reading of a person’s blood pressure.

Read more about Essential Hypertension »

Much rarer reasons for intracerebral hemorrhage include head trauma and tangles of abnormally formed blood vessels, known as arteriovenous malformations (AVMs).

Subarachnoid bleeding is commonly due to rupture of an aneurysm within the brain, an aneurysm being the swelling and bulging of an area in a blood vessel that forms, for example, due to a weak spot in an artery wall. The cause of an aneurysm may sometimes be unclear or caused by many individual, interacting factors. A possible reason for an aneurysm to develop may be a pre-existing condition that also leads to weaker blood vessel walls, such as Marfan syndrome or a type of Ehlers-Danlos syndrome. 7 There are various other causes of aneurysms, among them: 2

• High blood pressure
• The buildup of fatty deposits in the arteries
• Injuries to the head and brain,
• Some infections being among the more common ones

Read more about subarachnoid hemorrhage causes »

The risk of having a hemorrhagic stroke strongly increases with age, but the condition can affect younger people too. The most common risk factor for any kind of stroke is high blood pressure: nearly three quarters of those affected by a sudden stroke have high blood pressure. 8

Avoidable risk factors common to hypertension and therefore both types of hemorrhagic stroke include: 1 2

• Smoking tobacco products
• High alcohol use
• An unhealthy diet
• A lack of exercise
• The use of stimulant drugs such as cocaine, amphetamines and crystal meth

Other factors, which are also linked to hemorrhagic stroke include: 4 9

• Certain inherited conditions that weaken the blood vessels, such as autosomal dominant polycystic kidney disease (ADPKD)
• Vasculitis, when blood vessels inside the brain become swollen and inflamed, due to infection or to conditions affecting the immune system
• Brain infection, such as encephalitis
• Arteriovenous malformations (AVMs)
• Head and neck trauma
• When the ability to form blood clots is impaired, either due to certain medications or a bleeding disorder
• Cerebral amyloid angiopathy, a buildup of proteins on the walls of the arteries in the brain
• Brain tumours

If a stroke is suspected, then medical attention should be sought immediately. Diagnosis and treatment will usually take place in a hospital emergency room. The first stage of diagnosis will generally involve a review of the affected person’s medical history and a physical exam. This will be followed by several tests to confirm whether the person is affected by a stroke and, if so, what type of stroke it is.

A brain scan can help determine: 1

• Whether the stroke is hemorrhagic or ischemic
• Where the bleeding is taking place
• The amount of bleeding
• The damage that has been caused to the brain thus far

It can also help detect any potential brain abnormalities that may have contributed to or caused the stroke.

Given the risk of ongoing damage from an untreated stroke, a brain scan must be carried out promptly after the affected person reaches a hospital.

A magnetic resonance imaging (MRI) scan uses radio waves and a strong magnetic field to build a detailed image of the interior of the body. An MRI scan usually provides a more detailed picture than a CT scan, so could be beneficial if the injury is very small or might give slightly clearer results, depending on when it is run and the time that has passed since the stroke happened/symptoms started. 10

If a doctor wishes to get a more detailed view of the blood vessels in the body, they may insert a small amount of dye into the blood before performing a brain scan.

In a computed tomography angiogram (CTA scan) or a magnetic resonance angiogram (MRA), the dye is usually injected through an intravenous drip in the arm. It can also be injected into a vein on the back of the hand or by inserting a thin tube, known as catheter, through another blood vessel.

Good to know: Less commonly, a lumbar puncture may be made by a doctor if a subarachnoid hemorrhage (SAH) is suspected and a CT or MRI scan fails to confirm this diagnosis. This involves taking a sample of fluid from around the spinal cord and investigating it for signs of blood.

Read more about subarachnoid hemorrhage diagnosis ».

Treatment will generally focus on stabilising the person affected, reducing the level of pressure on the brain and, overall, stopping or minimising any brain damage. If there is a large amount of bleeding or a clot has formed in the brain, then surgery may be required. High blood pressure will usually be reduced gradually, if this is discovered to be a factor. 1

Some medications are given in the short-term to minimise the risk of complications. These may include: 4

• Blood pressure medication to prevent rebleeding
• Anticonvulsants, medication against seizures
• Certain diuretics to decrease the pressure in the subarachnoid space inside the head
• Treatment may be needed to reverse the effect of any blood-thinning medications, also known as anticoagulants, such as heparin or warfarin

After a hemorrhagic stroke, treatment may be needed to reverse the effect of any priorly taken blood-thinning medications, also known as anticoagulants. These can include: 11 12

• Vitamin K and fresh frozen plasma for reversing the effects of warfarin
• Protamine for reversing the effects of heparin
• Idarucizumab for reversing the effects of dabigatran

There are several scenarios in which surgery may be suggested to treat a hemorrhagic stroke. This may be to deal with complications caused by the bleeding, to stop the bleeding or to minimise the risk of the bleeding beginning again. Most hemorrhagic stroke surgery takes place in a special neurosurgical unit. 1 3

There is the risk during a hemorrhagic stroke that a blood clot may form in the brain. The resulting increase of pressure on the brain could lead to a number of potentially permanent health complications if not addressed in a timely fashion. One potential way of surgically correcting this is through first performing a craniotomy, a procedure in which doctors open up a small part of the affected person’s skull, followed by steps to remove the blood clot.There are several considerations that go into whether a person should have a craniotomy, including physical health, age and likelihood of recovery. If the hemorrhage is deep in the brain, such as in the basal ganglia or internal capsule regions, then surgery is usually not recommended.

Good to know: There are several surgical treatments that are specific to treating subarachnoid hemorrhages caused by burst aneurysms. These treatments are usually directed at sealing the aneurysm and stopping the bleeding.

Read more about subarachnoid hemorrhage treatments »

A person’s physical abilities are often restricted immediately after a stroke. The amount to which the person is affected varies from a feeling of numbness or weakness in parts of the body to a complete loss of power. Other commonly reported difficulties include difficulty swallowing and a loss of balance. This can lead to various problems, most of which can be managed by good nursing care, including:

• Deep vein thrombosis, dangerous blood clots which are more likely to form if the person is not moving around for long periods
• Unhealthy nutrition, because of difficulty swallowing or chewing
• Aspiration pneumonia, a type of pneumonia caused by food or drinks being accidentally inhaled into the lungs
• Falls and other accidents related to a sudden loss of balance and/or physical weakness

Physical rehabilitation will usually begin in the hospital to improve muscular function and is often continued in an inpatient or outpatient rehabilitation center after hospital discharge .

This is when a person experiences problems with one or more brain functions. Cognitive dysfunction affects most people who have experienced a hemorrhagic stroke to some degree.

Some common problems related to thinking include: 2

Memory problems, such as problems remembering names or faces, or making and keeping new memories.

Difficulty concentrating for longer periods of time, often on previously straightforward tasks, such as making a cup of tea, and being easily distracted.

Difficulty solving more complex tasks. This is due to increased tiredness, difficulty concentrating and other complex effects of the stroke. Some examples include:

• Tasks at work that require more thinking than routine behaviour
• Repairing broken objects in a logical order
• Solving crossword puzzles

Some people may find that their speech becomes slurred or slowed, or that they have difficulty finding the right words to express themselves. This usually improves gradually. A speech and language therapist can often help by giving specific advice on management of significant speech difficulties and by providing individualized treatment to help a person as much as possible in dealing with speech or language problems.

After a stroke, many people experience emotional problems, feel fearful of living with future complications or long-term disability, and may feel a loss of confidence in accomplishing everyday tasks or social activities.

These problems may include: 13 14 15

• Low, depressed mood and mood swings
• Clinical depression
• Crying or laughing easily, sometimes with no apparent reason or in socially inappropriate situations
• Feeling angry a lot more than previously
• The feeling that the person’s personality has changed
• Developing generalised anxiety disorder
• Developing post traumatic stress disorder
• Denial about the consequences of the stroke

Emotional difficulties tend to improve with time and treatment, and there are various treatment options available to help and support someone experiencing them, including:

• Support groups such as those the registered with the National Stroke Association
• Talking therapies, such as psychotherapy
• Medications, such as antidepressants

There are several serious complications that can occur after a hemorrhagic stroke. Those caring for the person affected by the stroke, as well as the person themselves, if they are able, need to be attentive and watch for any signs of these potential problems. Complications following a hemorrhagic stroke can increase the risk of long-term effects on a person’s health or may even lead to an increased risk of death and should therefore be treated as quickly as possible.

After a hemorrhagic stroke, there is some risk of the bleeding beginning once again. This is known as rebleeding and is most likely to occur in the few days after a stroke.

Seizures may develop after a hemorrhagic stroke, usually starting within the first year after the hemorrhage.

Symptoms of seizures usually last up to a few minutes per bout and commonly include: 16

• Loss of consciousness
• Muscle twitching and jerking
• Becoming stiff

Medications are available to treat and prevent seizures as much as possible, and some doctors may prescribe or recommend anti-seizure medication, even if a seizure is yet to occur.

For more on epilepsy, see this resource on generalized seizure.

Hemorrhagic stroke can possibly lead lead to disruption of the production and drainage of cerebrospinal fluid (CSF), which can lead to a buildup of fluid on the brain, known as hydrocephalus. This increases pressure on the brain, which can lead to (further) brain damage. Hydrocephalus is more likely to occur after subarachnoid hemorrhage than after intracranial bleeding. 17

Another complication that is more likely after an SAH than an ICH is vasospasm, which may lead to delayed cerebral ischemia. 4 9 18 A vasospasm occurs when a blood vessel goes into spasm, causing the vessel to narrow, and the blood supply to some parts of the brain to become dangerously low. Delayed cerebral ischemia is an umbrella term referring to one of the following after an SAH: ref25

• New problems in brain function or a deterioration in consciousness lasting over an hour
• The discovery of new obstructions of the blood supply to the brain (infarctions)

Read more about subarachnoid hemorrhage complications »

Q: Are there any hemorrhagic stroke recovery stories?
A: Yes. While rehabilitation and recovery after a stroke are difficult, there are numerous cases of people recovering the majority of their motor and cognitive functions after one has taken place. Support groups, such as those the registered with the National Stroke Association, often offer opportunities to meet other stroke survivors. Healthtalk.org includes a number of recovery stories by people of all ages.

Q: What is the prognosis for hemorrhagic stroke?
A: Following a hemorrhagic stroke, long-term disability or a person not surviving the stroke are a serious risk. A medical professional will be able to give guidance and support regarding a person’s long-term prognosis, but it is often hard to predict the outcome accurately, and, in the end, people may fare worse or much better than previously estimated.

Q: What is the difference between a hemorrhagic stroke and an ischemic stroke?
A: If a stroke does not feature bleeding, it is known as an ischemic stroke. This occurs most often when a blood vessel is blocked by a blood clot or a fatty deposit. In some cases, an ischemic stroke can turn into a hemorrhagic stroke. 19