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Haemorrhagic stroke

Your brain controls everything your body does, including your movement, speech, vision and emotions. To do this, your brain needs oxygen and nutrients, and if it doesn’t get these, it may be damaged. If there is damage to your brain, any of the things it controls may be affected.

A stroke is when the blood supply to your brain is interrupted. In a haemorrhagic stroke, this happens when an artery or vein – your blood vessels – bursts and bleeds (haemorrhages) into your brain. This stops your brain getting the oxygen and nutrients it needs. So it’s vital that you can recognise if you or someone you’re with is having a stroke and get immediate treatment.

There are different types of stroke – our information here is about haemorrhagic stroke. If an artery or vein bursts (ruptures) and bleeds into your brain, (a haemorrhage), the blood puts pressure on your brain and can damage it.

About 15 people out of every 100 who have a stroke have a haemorrhagic stroke. The condition mostly affects people over 65, but it can happen at any age.

The symptoms of a haemorrhagic stroke tend to be more severe than those caused by the more common type of stroke – ischaemic stroke. For more information about ischaemic strokes see Related information.

Types of haemorrhagic stroke

There are two main types of haemorrhagic stroke.

  • Intracerebral haemorrhage. This is when your stroke is caused by bleeding from a blood vessel inside your brain.
  • Subarachnoid haemorrhage. This is when your stroke is caused by bleeding from a blood vessel on the surface of your brain into the subarachnoid space. This is an area between your brain and the lining that covers it and contains fluid that surrounds your brain and spine (cerebrospinal fluid).
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Stroke
Dr Turner talks about risk factors for stroke

Details

  • Symptoms Symptoms of haemorrhagic stroke

    The symptoms of a stroke usually come on suddenly, within seconds or minutes.

    A good way to recognise if you or someone you’re with has had a stroke is to use the ‘FAST’ test.

    • Face. If you have had a stroke, you may have facial weakness and won't be able to smile. Your face may also look odd, for example, your mouth or eye may droop down, usually just on one side.
    • Arm. You won't be able to raise your arms and hold them there.
    • Speech. You may have slurred speech or find it difficult to remember the names of common objects.
    • Time to call 999. If you have one or more of these symptoms or see them in anyone else, it’s crucial to get emergency help straight away.

    Other symptoms of haemorrhagic stroke may include:

    • a sudden, very severe headache
    • losing consciousness
    • feeling sick or vomiting
    • a stiff neck
    • numbness, feeling weak or the inability to move your face, arm or leg on one side of your body
    • feeling dizzy and having vertigo
    • blurred vision or being sensitive to light
    • feeling confused
    • seizures (fits)
  • Diagnosis Diagnosis of haemorrhagic stroke

    When you get to hospital, you’ll have a number of tests. These will aim to find out what type of stroke you had and which part of your brain is affected. This will help your doctor to plan your treatment.

    You will have your blood pressure measured and an electrocardiogram (ECG) to record the rhythm and electrical activity of your heart. You may then have blood tests to measure your cholesterol and blood sugar levels, and to check how well your blood clots. You will also have a brain scan (for example, a CT or MRI) as soon as possible. This will help to find out what caused your stroke.

    If your doctor thinks you had a subarachnoid haemorrhage but your brain scan doesn’t show any bleeding, you may need a lumbar puncture. This test involves taking a sample of the fluid that surrounds your brain and spine (cerebrospinal fluid) from your lower back. This will be tested to see if there is any blood from your brain in it, which would confirm that you had a haemorrhagic stroke.

    If a lumbar puncture confirms that you have had a haemorrhagic stroke, you may need to have an angiogram. This test uses an injection of a special dye into your blood vessels to make them clearly visible on X-rays and scans. It will help to find out exactly where the bleeding in your brain is coming from. Often, it's an aneurysm, which is a weak spot in an artery wall that widens or bulges outwards and can burst.

  • Treatment Treatment of haemorrhagic stroke

    You may be treated in a specialist stroke unit in hospital.

    If you can’t swallow, you will be given fluid through a drip in your arm to stop you becoming dehydrated. You will have a tube in your nose to give you all the nutrients and medicines you need. You may also be given oxygen through a face mask to help you breathe.

    You will be helped to sit up and encouraged to move around as soon as you can. If you can’t move, your healthcare team will regularly help you to turn in your bed. This will reduce your risk of getting bed sores and deep vein thrombosis (DVT). You may also be given a mechanical pump to use on your feet and legs. This is called an intermittent compression device – they are safe and often used in hospitals. The pump automatically squeezes your feet and lower legs to help keep your blood moving and prevent a blood clot from forming.

    The length of time that you need to stay in hospital will vary and depends on how severely you have been affected by your stroke.

    Medicines

    The medicines you’re given will depend on the type of haemorrhagic stroke you've had and any medicines you may already be taking. For example, if you have an intracerebral haemorrhage and are taking an anticoagulant, you may need to take medicines that have the opposite effect. An anticoagulant is a medicine that reduces the ability of your blood to clot. Taking a medicine that has the opposite effect will allow your blood to clot and help stop further bleeding in your brain.

    You may also need to take some of the following medicines.

    • Anticonvulsants can help to prevent seizures.
    • Antihypertensives are often used to lower your blood pressure if it’s very high. This helps to prevent further bleeding.
    • Diuretics are sometimes used to lower the pressure in your brain if it’s very high.

    If you have a subarachnoid haemorrhage, you may need to take a medicine called nimodipine for a few weeks afterwards. This will help to keep the blood flowing in your brain.

    Surgery

    If you have had a haemorrhagic stroke, there is a risk that the bleeding may form a blockage as it clots. This may stop the flow of cerebrospinal fluid around your brain and cause a build-up of pressure (this is known as hydrocephalus). If this happens, your doctor may suggest you have a drain inserted to remove the excess fluid.

    If you've had an intracerebral haemorrhage in the back of your brain or near the surface, you may need surgery to drain away the blood. But this isn't suitable for everyone.

    If you've had a subarachnoid haemorrhage caused by a burst blood vessel inside your brain, you may need surgery to reduce any further bleeding. There are different operations to do this. The most common is endovascular coiling. In this procedure, your surgeon will pass a tube through a small cut in your groin into an artery. This is threaded through to reach the aneurysm in your brain and then small coils are placed within the aneurysm. This will seal the leak and stop the bleeding. Alternatively, you may have open surgery. Your surgeon will need to operate on your skull to reach the aneurysm and put a clip around its base to stop blood from leaking out.

    Talk to your surgeon about which type of operation is most suitable for you.

    Rehabilitation

    A stroke can damage your brain. Because your brain controls everything you do, if it’s damaged you may need to relearn skills and abilities, or learn new ways of doing things. This is known as stroke rehabilitation.

    It can be difficult to predict how well you will recover from a stroke. You may find you make most of your recovery in the early weeks and months following the stroke. However, your recovery may continue after this time and you may carry on improving for years afterwards.

    A multidisciplinary team of health professionals will work out a rehabilitation programme for you that's designed around your particular needs. The team may include physiotherapists, speech and language therapists, occupational therapists, ophthalmologists and psychologists, as well as doctors and nurses. Your rehabilitation will aim to help you stay as independent as possible.

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  • Causes Causes of haemorrhagic stroke

    A haemorrhagic stroke is caused by a blood vessel within your skull bursting and bleeding into and around your brain. High blood pressure plays a part in the majority of haemorrhagic strokes. If you have high blood pressure, there is extra strain on your smaller blood vessels so they are more likely to burst. You’re at a greater risk of high blood pressure if you:

    • eat too much salt and sugar, and not enough fruit or vegetables
    • don’t do enough exercise
    • are overweight or obese
    • drink too much alcohol

    You’re more at risk of having a haemorrhagic stroke as you get older. And there are other things that may increase your risk of having a haemorrhagic stroke – we’ve explained some of them here.

    • An aneurysm in your brain, which is a weak spot in your artery wall that widens or bulges outwards and can burst. An aneurysm can be caused by high blood pressure, or some people have a family history of aneurysms.
    • A condition called cerebral amyloidosis can lead to a build-up of a substance called amyloid in the blood vessels in your brain. This can damage your blood vessels so they may burst and bleed.
    • Abnormalities in the way that blood vessels have formed in your brain. This is called an arteriovenous malformation or a cavernoma. See our FAQs for more information.
    • Anything that increases your tendency to bleed. This could be treatment with an anticoagulant medicine that reduces your blood’s ability to clot (for example, warfarin). Or it may happen if you have a health condition that affects how your blood clots, such as haemophilia.
    • Using illegal drugs, such as cocaine. • Having a head injury. This may cause blood vessels to burst and bleed into or around your brain.
  • Complications Complications of haemorrhagic stroke

    A haemorrhagic stroke can be very severe and cause lasting damage to your brain. Sometimes they can even be fatal. Complications of a stroke may include:

    • weakness or paralysis, often on one side of your body
    • loss of sensation in your body
    • difficulty swallowing
    • problems sleeping
    • problems with speech, reading and writing
    • problems with vision – for example, double vision or partial blindness
    • problems with your memory and concentration
    • difficulty controlling your bladder and bowel movements (incontinence or constipation)
    • changes in your personality and behaviour

    Problems such as anxiety, depression and seizures may improve as you recover.

    If you can’t move because of stroke, you could be at risk of:

    • bed sores (pressure ulcers)
    • DVT (deep vein thrombosis) – this is a blood clot in a vein in your leg
    • pneumonia 
    • contractures (altered position of your hands, feet, arms or legs because of muscle tightness)
  • FAQs FAQs

    Is haemorrhagic stroke more serious than ischaemic stroke?

    Answer

    Haemorrhagic strokes tend to be more severe than ischaemic strokes. But always keep in mind that the effects of any type of stroke and your recovery afterwards will vary from person to person.

    Explanation

    Haemorrhagic strokes are often more severe than ischaemic strokes and are also more likely to be fatal, but remember everyone is different. Both haemorrhagic and ischaemic strokes can be fatal for some people, whereas others recover well and manage with any brain damage caused by a stroke.

    The sooner you get treatment after a stroke, the better your chance of recovery. It's therefore very important to call for emergency help as soon as you recognise the symptoms of stroke. Check for these using the ‘FAST’ test. This stands for:

    • face – facial weakness (you probably won't be able to smile and your face may droop)
    • arm – arm weakness (you won't be able to raise your arms and hold them up)
    • speech – problems speaking (your speech may be slurred or you might not remember the names of things)
    • time to call 999

    If you or someone you’re with has one or more of these symptoms, it’s vital to call for emergency help immediately.

    How does cocaine cause a haemorrhagic stroke?

    Answer

    The exact way in which cocaine causes a stroke isn't fully understood. But what is known is that if you use cocaine, you may increase your risk of having a haemorrhagic stroke.

    Explanation

    Cocaine causes blood vessels to narrow (constrict), which can slow down or stop the flow of blood through them. This is called a ‘spasm’ and can weaken your blood vessels and make them more likely to burst. Taking cocaine can also lead to a sudden, temporary rise in blood pressure, which increases your risk of a haemorrhagic stroke.

    What is an arteriovenous malformation and how will I know if I have one?

    Answer

    An arteriovenous malformation (AVM) is a tangle of blood vessels that forms when your blood vessels don't connect together properly in your brain. You may not know that you have an AVM as often they don’t cause any problems. But some people with an AVM can get symptoms that may include headaches and seizures (fits).

    Explanation

    Your arteries are connected to your veins by a network of very fine blood vessels called capillaries. Arteries are blood vessels that carry blood away from your heart and veins are blood vessels that carry blood back to it. In an AVM, the capillaries are missing and your arteries and veins join together in a complex tangle of weakened blood vessels. Over time, the pressure of the blood in the tangle can eventually lead to a blood vessel bursting, which is called a haemorrhage.

    It’s thought that AVMs affect up to one in 100 people in the general population. Often though, you may not even realise you have one because it's usually something you're born with and doesn't cause any symptoms.

    If your doctor finds out that you have an AVM, they may recommend monitoring it. If there is a risk of it bursting and bleeding, they may advise you to have surgery to remove it. Other treatments involve blocking the blood vessels that make up the AVM with a glue-like material (embolisation), or destroying the AVM with focused radiation beams. This is called gamma knife radiosurgery and will help to reduce your risk of stroke.

  • Resources Resources

    Further information

    Sources

    • Hemorrhagic stroke. Medscape. www.emedicine.medscape.com, published 6 October 2014
    • National clinical guideline for stroke. Royal College of Physicians. www.rcplondon.ac.uk, published September 2012
    • NINDS stroke information page. National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov, published 14 October 2014
    • Brain anatomy. Medscape. www.emedicine.medscape.com, published 15 February 2013
    • Stroke and TIA. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published December 2013
    • Haemorrhagic stroke. BMJ Best Practice. www.bestpractice.bmj.com, published 31 October 2014
    • Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). National Institute for Health and Care Excellence (NICE), July 2008. www.nice.org.uk
    • Prevention of venous thromboembolism. PatientPlus. www.patient.co.uk/patientplus.asp, published June 2014
    • VTE prophylaxis. BMJ Best Practice. www.bestpractice.bmj.com, published December 2014
    • Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 12 November 2014
    • Stroke rehabilitation. National Institute for Health and Care Excellence (NICE), June 2013. www.nice.org.uk
    • Stroke treatments. American Stroke Association. www.strokeassociation.org, published 1 October 2014
    • Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42(2):517–84. doi:10.1161/STR.0b013e3181fcb238
    • Hypertension. Medscape. www.emedicine.medscape.com, published 30 September 2014
    • Cerebrovascular events. PatientPlus. www.patient.co.uk/patientplus.asp, published 16 May 2012
    • Arteriovenous malformations and other vascular lesions of the central nervous system fact sheet. National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov, published February 2011
    • What is an arteriovenous malformation (AVM)? American Stroke Association. www.strokeassociation.org, published 20 June 2014
    • Arteriovenous malformations. Medscape. www.emedicine.medscape.com, published 27 March 2014
    • Stereotactic radiosurgery for patients with intracranial arteriovenous malformations (AVM). International Radiosurgery Association. www.irsa.org, published March 2009
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