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Haemorrhagic stroke

Haemorrhagic stroke is when the blood supply to your brain is cut off when a blood vessel bursts and bleeds (haemorrhages) into your brain. This stops your brain getting the oxygen and nutrients it needs, and the blood puts pressure on your brain, which can damage it. The sooner you get treatment for a haemorrhagic stroke, the less damage is likely to happen.

Stroke
Dr Turner talks about risk factors for stroke

Details

  • Types Types of haemorrhagic stroke

    There are different types of stroke. This topic is about haemorrhagic stroke, but we also have information about ischaemic stroke.

    About 15 people out of every 100 who have a stroke have a haemorrhagic stroke. And there are two main types.

    • Intracerebral haemorrhage. This is caused by bleeding from a blood vessel inside your brain and is the most common type.
    • Subarachnoid haemorrhage. This 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 cerebrospinal fluid that surrounds your brain and spine.
  • Symptoms Symptoms of haemorrhagic stroke

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

    It’s vital that you can recognise if you, or someone you’re with, is having a stroke so you can get immediate treatment. A good way to remember the signs of one is to use the ‘FAST’ test.

    • Face. If you’ve had a stroke, your face may feel weak and you won't be able to smile. Your mouth or eye may droop down, usually just on one side.
    • Arm. You won't be able to raise your arm and hold it 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 you see them in anyone else, get emergency help straightaway.

    Other symptoms of a haemorrhagic stroke may include:

    • a sudden, very severe headache
    • losing consciousness
    • feeling sick or vomiting
    • a stiff neck
    • feeling numb or weak, or unable to move your face, arm or leg on one side of your body
    • feeling dizzy
    • vertigo
    • blurred or double vision – or difficulty seeing at all
    • feeling confused
    • seizures (fits)
  • Diagnosis Diagnosis of haemorrhagic stroke

    When you get to hospital, you’ll have some tests to find out what type of stroke you’ve had and how your brain is affected. This will help your doctor to plan your treatment.

    These include:

    • a brain scan such as a computer tomography (CT) or magnetic resonance imaging (MRI) to find out what caused your stroke
    • an electrocardiogram (ECG) to record the rhythm and electrical activity of your heart
    • blood tests to measure your pressure, cholesterol and blood sugar levels, and to check how well your blood clots

    Lumbar puncture

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

    Angiogram

    If a lumbar puncture does confirm that you’ve had a haemorrhagic stroke, you may need to have an angiogram. In this test, your doctor will inject a dye into your blood vessels to make them show up on X-rays and scans. It will help to find out exactly where the bleeding in your brain is coming from.

  • Treatment Treatment of haemorrhagic stroke

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

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

    Nurses will help you to sit up and encourage you to move around as soon as you can. If you can’t move, they’ll help you to turn in your bed regularly. 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 called an intermittent compression device. The pump automatically squeezes your feet and lower legs to help keep your blood moving and prevent a blood clot from forming.

    How long you’ll need to stay in hospital will depend on how severe your stroke was and how you’ve been affected by it.

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  • Medicines Medicines for haemorrhagic stroke

    The medicines your doctor will give you will depend on the type of haemorrhagic stroke you've had, and if you’re taking any other medicines.

    If you’ve had 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 might also need to take:

    • anticonvulsants, which can help to prevent seizures
    • antihypertensives to lower your blood pressure if it’s very high, to prevent further bleeding
    • diuretics 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 Surgery for haemorrhagic stroke

    If you’ve had a haemorrhagic stroke, you might need to have surgery. Which type of surgery you have will depend on the type of haemorrhagic stroke you’ve had and your own personal circumstances. Your doctor or surgeon will be able to advise which type of surgery is best for you.

    The types and reasons for having surgery are outlined below.

    Bleeding in your brain from a haemorrhagic stroke can cause pressure to build up and clots to form. You might have surgery to drain the bleed and remove any blood clots – this is known as evacuation. There are lots of different types of surgery to do this. One type involves removing a piece of your skull (known as craniotomy). During this procedure your surgeon can fix the blood vessel, drain the bleed and remove any clots. Other types of surgery involve drilling small holes in your skull and then draining the bleed and any clots using a needle or endoscope (a very small tube-like telescopic camera). Other procedures, involve using CT (computed tomography) to find out where the bleed is, and then a special piece of equipment to suck up the bleed and any clots.

    You may also need surgery to reduce the chance of more bleeding (rebleeding). If bleeding is caused by an aneurysm (see our causes section below for more information), you may have a procedure called endovascular coiling. This stops blood pooling into the aneurysm, reducing the chance of it bursting again. In this procedure, your surgeon passes a tube through a small cut in your groin into an artery. They thread this through to reach the aneurysm in your brain and then put small coils in it. This is the most common procedure, but you may have a craniotomy. During the craniotomy, your surgeon puts a clip around the base of the aneurysm to stop it bleeding again.

    Some haemorrhagic strokes might cause the amount of cerebral spinal fluid in your brain to increase (hydrocephalus). This raises the pressure in your brain and makes you feel less alert. If this happens, you might need to have the fluid removed. Procedures such as ventricular drainage and lumbar puncture can be used to relieve the pressure. Lumbar puncture is a procedure that might also be used to help diagnose haemorrhagic stroke – see our diagnosis section for more information.

    For more information on surgery for haemorrhagic stroke, talk to your doctor or surgeon
  • Rehabilitation Rehabilitation after haemorrhagic stroke

    A stroke can damage your brain. Since your brain controls everything you do, 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’ll recover from a stroke. You might make most of your recovery in the first weeks and months after the stroke. But you might continue to get better and 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 needs. The team may include physiotherapists, speech and language therapists, occupational therapists, ophthalmologists and psychologists, as well as doctors and nurses. They’ll work together to help you stay as independent as possible.

  • 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 most haemorrhagic strokes – this puts extra strain on your smaller blood vessels so they’re more likely to burst.

    You’re also more at risk of having a haemorrhagic stroke as you get older. Although you can have a stroke at any age, most people who have one are over 65. And men are more likely to have one than women. Other things that may increase your risk of having a haemorrhagic stroke include the following.

    • An aneurysm in your brain, which is a weak spot in your artery wall that widens or bulges outwards and can sometimes burst. An aneurysm can be caused by smoking or high blood pressure, or some people have a family history of them.
    • Cerebral amyloidosis, which is a condition where a substance called amyloid builds up 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 FAQ: What’s arteriovenous malformation? 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. See FAQ: Cocaine and haemorrhagic strokes below.
    • Drinking too much alcohol increases your risk of a haemorrhagic stroke too.
  • Complications Complications of haemorrhagic stroke

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

    • weakness or paralysis, often on one side of your body
    • difficulty swallowing
    • problems sleeping
    • problems with speech, reading and writing
    • problems with your sight – for example, you might get double vision or find it hard to see
    • problems with your memory and difficulty concentrating
    • difficulty controlling your bladder and bowel movements (incontinence or constipation)
    • changes in your personality and behaviour
    • anxiety and depression 

    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 (where your hands, feet, arms or legs become so tight that it’s hard to straighten them)
  • Prevention Prevention of haemorrhagic stroke

    High blood pressure plays a part in most haemorrhagic strokes so you could take steps to reduce this. For tips on how, see our topic on high blood pressure.

    You can also prevent a haemorrhagic stroke by not using illegal drugs such as cocaine. If you drink a lot of alcohol or smoke, it’s a good idea to cut down. And try to eat well. See Related information for tips and advice on achieving these.

  • FAQ: Severity of different strokes Is haemorrhagic stroke more serious than ischaemic?

    Haemorrhagic strokes are often more severe than ischaemic strokes and are also more likely to be fatal, but everyone is different. Both haemorrhagic and ischaemic strokes can be fatal for some people, whereas others recover well and manage with the effects of a stroke.

  • FAQ: Arteriovenous malformation What’s arteriovenous malformation?

    An arteriovenous malformation (AVM) is a tangle of blood vessels that forms when your blood vessels don't connect together properly in your brain. Most people aren’t aware they have an AVM as they don’t usually cause any problems. But you might get symptoms such as headaches and seizures (fits). 

    More information

    Your arteries are connected to your veins by a network of very fine blood vessels called capillaries. 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.

    If your doctor finds out that you have an AVM, they’ll probably want to monitor it. If it’s likely to burst and bleed, they may suggest you have an operation to remove it. Other treatments involve blocking the blood vessels that make up the AVM with a glue-like material (embolisation), or destroying it with focused radiation beams. This is called gamma knife radiosurgery.

  • FAQ: Cocaine and haemorrhagic strokes How does cocaine cause a haemorrhagic stroke?

    Cocaine causes your blood vessels to suddenly narrow, 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 too.

  • Other helpful websites Other helpful websites

    Further information

    Sources

    • Haemorrhagic stroke. BMJ Best Practice. bestpractice.bmj.com, last updated 26 April 2016
    • Hemorrhagic stroke. Medscape. emedicine.medscape.com, updated 8 January 2015
    • Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. National Institute for Health and Care Excellence (NICE), 23 July 2008. www.nice.org.uk
    • Brain anatomy. Medscape. emedicine.medscape.com, updated 24 April 2015
    • Map of medicine. Stroke and transient ischaemic attack (TIA). International view. London: Map of medicine; 2016 (issue 2)
    • Stroke and TIA. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised December 2013
    • Subarachnoid haemorrhage. PatientPlus. patient.info/patientplus, last checked 14 January 2015
    • National clinical guideline for stroke. Royal College of Physicians. www.rcplondon.ac.uk, published September 2012
    • Oral anticoagulants. NICE British National Formulary. www.evidence.nhs.uk/formulary/bnf/current, accessed 19 August 2016
    • Nimodipine. NICE British National Formulary. www.evidence.nhs.uk/formulary/bnf/current, accessed 19 August 2016
    • Cerebrovascular event rehabilitation. PatientPlus. patient.info/patientplus, last checked 2 August 2013
    • NINDS stroke information page. National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov, last modified 26 May 2016
    • Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Scottish Intercollegiate Guidelines Network (SIGN), June 2010. www.sign.ac.uk
    • Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45(12):3754–832. doi: 10.1161/STR.0000000000000046
    • Arteriovenous malformations. Medscape. emedicine.medscape.com, updated 27 March 2014
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  • Related information Related information

  • Author information Author information

    Reviewed by Rachael Mayfield-Blake, Freelance Health Editor, October 2016
    Expert reviewer Dr Ahamad Hassan, Consultant Neurologist and Stroke
    Next review due October 2019

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