What Is It?

A Hemorrhagic stroke is bleeding (hemorrhage) that suddenly interferes with the brain’s function by cutting off part of its blood supply. This bleeding can occur either within the brain itself or between the brain and the skull. Hemorrhagic strokes account for about 20 percent of all strokes, and are divided into several different categories depending on the site and cause of bleeding:

• Intracerebral hemorrhage — In this type of Hemorrhagic stroke, bleeding occurs from a broken blood vessel within the brain itself. Major risk factors for this type of stroke include high blood pressure (hypertension), heavy alcohol use, advanced age and the use of either cocaine or amphetamines. It is possible for a stroke without hemorrhage (a thrombotic or embolic stroke) to cause intracerebral hemorrhage as a consequence. This is particularly common for embolic strokes when the embolus (a floating mass within the bloodstream) contains bacteria and inflammatory cells, such as when a person has infective endocarditis. In rare cases, intracerebral hemorrhage also may happen because of a leaking Arteriovenous malformation (AVM), a weak-walled blood vessel that is a hybrid between an artery and a vein. An AVM is present from birth.



• Subarachnoid hemorrhage — In this type of brain hemorrhage, bleeding from a damaged blood vessel causes an accumulation of blood at the surface of the brain. Blood from a subarachnoid hemorrhage fills a portion of the space between the brain and the skull, and it mixes with the cerebrospinal fluid that cushions the brain and spinal cord. The large accumulation of blood acts like an enlarging mass that grows and presses on the brain, interfering with brain function. In addition, bleeding from a subarachnoid hemorrhage interrupts the vital blood supply to an area of the brain that normally is fed by the ruptured blood vessel. Most often, a subarachnoid hemorrhage happens because of a burst saccular aneurysm (a sac-like bulge in the wall of an artery), but it also can occur because of leakage from an AVM.

Symptoms of a Hemorrhagic stroke vary, depending on the cause:

• Intracerebral hemorrhage — Symptoms of an intracerebral hemorrhage almost always occur when the patient is awake. In some cases, they seem to be brought on by stressful situations. Symptoms tend to appear without warning, but the onset of symptoms can be very gradual. Symptoms worsen over a period of 30 to 90 minutes. These symptoms can include sudden weakness, paralysis or numbness in any part of the body, inability to speak, sudden deviation of the eyes toward one direction, vomiting, difficulty walking, irregular breathing, stupor and coma.



• Subarachnoid hemorrhage — When a subarachnoid hemorrhage is caused by a ruptured aneurysm, the symptoms can include a very severe headache, loss of consciousness, nausea and vomiting, inability to look at bright light, stiff neck, dizziness and confusion. When a subarachnoid hemorrhage is caused by a leaking AVM, the symptoms can include a throbbing headache, and, sometimes, a seizure. Seizures occur in 30 percent of cases.

Your doctor will want to know your medical history and your risk factors for stroke. Your doctor will take your blood pressure and examine you, including a neurological exam and a heart exam.

To diagnose and classify your stroke, your doctor will require an imaging test of the brain. Several brain imaging tests can be useful, including a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of your brain. For Hemorrhagic strokes, CT scans are the fastest and most effective diagnostic test. If a subarachnoid hemorrhage is suspected, your doctor may perform a lumbar puncture, also called a spinal tap, in which a small sample of cerebrospinal fluid is removed through a needle inserted into your back. This fluid is examined to see if it contains blood. Another test, called an MRI angiography, can provide information about blood flow to your brain.

If these tests show that you are having a stroke, then you will undergo tests to check for a cause. Because a Hemorrhagic stroke involves bleeding, it is important to assess the ability of your blood to clot. If you take a blood-thinning medication called warfarin (Coumadin), which can contribute to a stroke, your blood’s thinness will be tested. If the infection endocarditis is suspected, blood samples will be drawn and incubated in a laboratory to determine if there are bacteria in the bloodstream. Other tests can reveal whether you have atherosclerosis or other causes of blood clotting in the heart or large arteries. You also may have an electrocardiogram (EKG) and chest X-ray. Blood tests will be done to evaluate your blood-cell counts and blood-clotting abilities. Some patients will have ultrasound testing of the arteries in the neck (carotid Doppler) or of the heart (echocardiogram).

Hemorrhagic stroke is life threatening. Up to half of all people with intracerebral hemorrhage die, and many of these deaths occur within the first two days. For those who survive a brain hemorrhagic, recovery is slow. Only 12 percent of people are able to recover complete or near-complete functioning within 30 days of the stroke.

You can help to prevent stroke from intracerebral hemorrhage by controlling your blood pressure. If you take warfarin, educate yourself about the effect other drugs and foods can have on the level of the drug in your bloodstream. Too much warfarin in your blood can cause bleeding. You also should be treated for High cholesterol, avoid excessive alcohol use and never use cocaine or amphetamines. Smoking has been shown to increase the risk of an aneurysm, so avoiding smoking may prevent some cases of Hemorrhagic stroke.

It is almost impossible to prevent subarachnoid hemorrhage caused by an aneurysms or AVM, because these blood vessel abnormalities usually do not cause any symptoms before the hemorrhage occurs.

Some people have proposed screening tests, such as MRI angiography, that would identify aneurysms before they cause a problem. However, this idea has been impractical for most people, because surgery to remove an aneurysm that is not causing any symptoms involves significant risks, and most aneurysms never cause serious bleeding. This screening may make sense for some people who have two or more close relatives who have had intracerebral hemorrhages. Because aneurysm screening is controversial, you should consider the risks of surgery carefully with your doctor before you request a screening test.

When a large hemorrhage occurs in or around the brain, the entire brain is in danger because of increasing pressure within the skull. Much of the emergency treatment for Hemorrhagic stroke involves measuring and lowering the intracranial pressure. A mechanical ventilator frequently is used to hyperventilate the stroke patient, because this can result in lower, safer pressure. The sugar mannitol, which sometimes is used as a medicine, pulls brain fluid into the bloodstream, also lowering intracranial pressure. If necessary, surgical cuts will be made in the skull bone to decrease the compression of the brain tissue. In some cases, surgery is necessary to remove a large portion of the clot after a hemorrhage, but in most patients, the body eventually reabsorbs the clotted blood on its own.

In the hours after a Hemorrhagic stroke, high blood pressure must be lowered gradually to safe levels. However, doctors consider the amount of brain swelling that is present when they decide what level is most appropriate.

Many doctors prescribe anti-seizure medication as a routine protective measure, and this medicine may be continued for six months or more following the stroke. In the case of subarachnoid hemorrhage, which commonly provokes spasm of the arteries that are nearest to the site of bleeding, medicines may be used to prevent arteries from narrowing in spasm.

If bleeding occurred because of an abnormally formed blood vessel, then surgery may be appropriate to prevent a hemorrhage from happening again. An aneurysm can be repaired by placing a surgical clip. Depending upon the size and location of an AVM, a neurosurgeon may be able to repair or remove an AVM.

Early intervention by an occupational therapist and physical therapist is helpful. These therapists are professionals who can assist a patient to work around a new disability and to regain strength after brain injury. Commonly, hospitalization is followed by a period of residence at a rehabilitation center, where additional intensive therapy may be provided. The goal of rehabilitation is to maximize recovery.

Call for emergency help immediately whenever a friend or family member shows any symptoms of stroke, especially if that person losses consciousness or suddenly develops a seizure. Also call your doctor promptly if you develop a severe headache with vomiting. Less intense headaches also should be evaluated by your doctor if they occur frequently or are accompanied by other symptoms, such as nausea, vomiting, weakness or numbness in any part of the body. If you take the medicine warfarin, you should be especially vigilant about reporting a new headache to your doctor.

If you have a sudden, very severe headache that goes away, it is still important to discuss this with your doctor. Sometimes blood leaks briefly from a blood vessel six to 20 days before a subarachnoid hemorrhage occurs. The headache this leak causes is called a sentinel headache. Your doctor may be able to provide treatment that can prevent more serious bleeding.

About 30 percent to 60 percent of patients with an intracerebral hemorrhage die. In those who survive long enough to reach an emergency room, bleeding usually has stopped by the time they are seen by a doctor. Many patients with ruptured aneurysms or a subarachnoid hemorrhage also do not survive long enough to reach a hospital. Of those who do, about 50 percent die within the first month of treatment. However, in patients with subarachnoid hemorrhages resulting from AVMs, the risk of death is only about 15 percent.

Among the 25 percent of patients who survive an intracerebral hemorrhage, many experience a major improvement in their symptoms as their bodies naturally and gradually reabsorb the clotted blood within the brain. Among patients who survive a bleeding aneurysm, about 50 percent suffer long-term neurological problems. One out of five survivors of subarachnoid hemorrhage has an untreated aneurysm or AVM have bleeding again within 14 days, and 50 percent within six months. When surgery is used to clip a bleeding aneurysm, there is a good chance of success, but there is also a 5 percent risk of death or long-term disability.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.