Published by Bupa's Health Information Team, February 2011.

This factsheet is for people who have had a haemorrhagic stroke, or who would like more information about it.

A stroke happens when the blood supply to the brain is interrupted. In a haemorrhagic stroke, a blood vessel bursts and bleeds into the brain.

About haemorrhagic stroke
Symptoms of haemorrhagic stroke
Complications of haemorrhagic stroke
Causes of haemorrhagic stroke
Diagnosis of haemorrhagic stroke
Treatment of haemorrhagic stroke

About haemorrhagic stroke

A haemorrhagic stroke happens when a blood vessel bursts and bleeds into your brain (a haemorrhage). This damages your brain cells and they begin to die. There are two main types of haemorrhagic stroke.

•    Intracerebral haemorrhage. This means your stroke has been caused by bleeding inside your brain.
•    Subarachnoid haemorrhage. This means your stroke has been caused by bleeding on the surface of your brain in the subarachnoid space (formed by two membranes that cover the brain).

Your brain controls everything your body does, including your movement, speech, vision and emotions. Damage to your brain can affect any of these functions.

About one in six people who have a stroke have a haemorrhagic stroke. They mostly affect older people, but can happen at any age.


Symptoms of haemorrhagic stroke

Stroke symptoms usually come on suddenly, within seconds or minutes.

A good way to recognise if someone has had a stroke is to use the face–arm–speech–time to call 999 test (abbreviated to FAST). This involves checking for any one of the three main symptoms of stroke – facial weakness, arm weakness or speech problems.

The symptoms of haemorrhagic stroke may include:  
•    having a very severe, sudden headache
•    losing consciousness (if this is prolonged, it’s called a coma)
•    vomiting
•    having a stiff neck
•    numbness, weakness or inability to move your face, arm or leg on one side of your body
•    difficulty speaking and being understood
•    feeling dizzy and having vertigo
•    difficulty keeping your legs straight and raising them
•    having a fever
•    being sensitive to light
•    feeling restless and confused (delirious)
•    having seizures (fits)

If you notice that someone has any of these symptoms, you should call for emergency help straight away.


Complications of haemorrhagic stroke

Some haemorrhagic strokes may be quite mild and their effects only temporary, whereas others may be more severe and cause lasting damage. Complications of stroke may include:

•    weakness or paralysis, usually on one side of your body
•    lack of awareness of one side of your body (usually the left side)
•    loss of sensation on one side of your body
•    difficulty swallowing
•    extreme tiredness and sleep problems
•    problems with speech, reading and writing
•    problems with vision – for example, double vision or partial blindness
•    memory and concentration difficulties
•    difficulty controlling your bladder and bowel movements (incontinence) or constipation
•    behavioural changes

Problems such as anxiety, depression and seizures (fits) can often improve as you recover.

If you are unable to move because of stroke, you could be at risk of:
•    bed sores (pressure ulcers)
•    deep vein thrombosis (DVT)
•    pneumonia
•    contractures (altered position of your hands, feet, arms or legs because of muscle tightness)

Causes of haemorrhagic stroke

The greatest risk factor for haemorrhagic stroke is having high blood pressure. About two in three haemorrhagic strokes are caused by this factor.

Other factors that may increase your risk of haemorrhagic stroke include the following.

•    Swelling of a blood vessel in your brain (intracranial aneurysm). This may be caused by high blood pressure, or may just be something you're born with.
•    Weakening of the blood vessels in your brain. This can happen because of uncontrolled blood pressure or sometimes because of a build-up of a protein called amyloid in the blood vessel walls (cerebral amyloidosis).
•    Abnormalities in the way in which blood vessels have formed in your brain (arteriovenous malformation).
•    Anything that increases your tendency to bleed. This can include having treatment with an anticoagulant medicine (eg warfarin) or having a condition such as leukaemia or haemophilia.
•    Use of some illegal drugs, such as cocaine.
•    Having a head injury. This may cause blood vessels to burst and bleed into or around your brain.


Diagnosis of haemorrhagic stroke

You will have a number of tests in hospital to try and find out what type of stroke you had and which part of your brain is affected. This will allow 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 (eg a CT or MRI) as soon as possible. This will help to find out if your stroke happened because of a bleed or a blockage.

If your doctor thinks you had a subarachnoid haemorrhage, you will have a lumbar puncture (a test in which a sample of cerebrospinal fluid is taken from the lower back). Then, once your condition is confirmed, you will have an angiogram (a test that uses an injection of a special dye into the blood vessels to make them clearly visible on X-ray images or CT). This will help your doctor to find out where the bleeding is in your brain.

Treatment of haemorrhagic stroke

When you go to hospital, you may be treated on a general ward or in a specialist stroke unit.

If you're unable to 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, if you need it, to help you breathe.

You will be helped to sit up and move around as soon as you are able. If you're unable to move, you will be helped to regularly turn in your bed, to reduce your chance of getting bed sores and DVT.


Medicines

The medicines you have will depend on the type of haemorrhagic stroke you have and any medicines you may already be taking. For example, if you have an intracerebral haemorrhage and are taking an anticoagulant (such as warfarin), you may need medicines to reverse the effects. This will allow your blood to clot and help stop the bleeding in your brain.

You may also have some of the following medicines.

•    Anticonvulsants such as phenytoin are used to prevent seizures.
•    Antihypertensives such as labetalol are often used to control your blood pressure if it’s very high. This helps to prevent further bleeding.
•    Diuretics such as mannitol can help to reduce the swelling in your brain.
If you have a subarachnoid haemorrhage, you may need to take a medicine called nimodipine for about three weeks after you had your stroke. This helps to keep the blood flowing to your brain.

Surgery

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

If you have an intracerebral haemorrhage in the back part of your brain (cerebellum) or near to the surface, you may need surgery to drain the blood away. However, this isn't suitable for everyone.

If you have a subarachnoid haemorrhage caused by an intracranial aneurysm, you may need surgery to reduce your risk of further bleeding. You may have endovascular treatment. In this procedure, your surgeon passes a tube through a small cut in your groin to reach the aneurysm in your brain. Small coils are placed within the aneurysm to stop the bleeding. Alternatively, you may have open surgery. In this procedure, your surgeon opens up your skull to reach the aneurysm. Your surgeon will advise you which operation is most suitable.

Rehabilitation

After a stroke, you may need to relearn skills and abilities, or learn new skills and adapt to the damage a stroke has caused. This is known as stroke rehabilitation.

Stroke recovery can be difficult to predict. Most people will make most of their recovery in the early weeks and months following the stroke. However, recovery can continue after this time.

The stroke team at the hospital will work out a rehabilitation programme for you that will be designed around your particular needs. This will continue after you leave the hospital. Your rehabilitation programme may involve physiotherapists, speech and language therapists, occupational therapists, ophthalmologists and psychologists, as well as doctors and nurses.

Published by Bupa's Health Information Team, February 2011.

This section contains answers to common questions about this topic. Questions have been suggested by health professionals, website feedback and requests via email.

Is a haemorrhagic stroke worse than an ischaemic stroke?
How does cocaine cause a haemorrhagic stroke?
What is an arteriovenous malformation and how will I know if I have one?


Is a haemorrhagic stroke worse than an ischaemic stroke?

Haemorrhagic strokes tend to be more severe than ischaemic strokes. However, the effects of any type of stroke, and recovery afterwards, vary from person to person.

Explanation

Haemorrhagic strokes are often more severe than ischaemic strokes and are also more likely to be fatal. However, the damage caused by any type of stroke, and the recovery made afterwards, vary from person to person. For example, both haemorrhagic and ischaemic strokes can be fatal for some people, whereas other people can recover well and learn to cope with the damage caused.

The sooner someone who has had a stroke gets treatment, the better their chance of recovery. It's therefore very important to call for emergency help as soon as your recognise the symptoms of stoke.

How does cocaine cause a haemorrhagic stroke?

The exact way in which cocaine causes a stroke isn’t fully understood. However, if you use cocaine and have a pre-existing condition that affects the blood vessels in your brain, you may be at greater risk of having a stroke.

Explanation

Cocaine causes blood vessels to constrict (narrow), leading to a sudden, temporary rise in blood pressure. This can weaken your blood vessels, causing them to burst. Although it’s not fully understood how cocaine causes a stroke, you may be more at risk if you have:

•    a swelling of a blood vessel in your brain (intracranial aneurysm)
•    abnormalities in the way in which blood vessels are formed in your brain (arteriovenous malformation)

A haemorrhagic stroke can occur within seconds of you taking cocaine. However, it can also occur as much as 12 hours later.

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

An arteriovenous malformation (AVM) is a tangle of blood vessels, which forms when your blood vessels don't connect together properly in your brain. Many people are unaware they have an AVM, although they can sometimes cause symptoms such as headaches and seizures (fits).

Explanation

Normally, your arteries (the blood vessels that carry blood away from your heart) are connected to your veins (blood vessels that carry blood back to your heart) 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. This puts the blood in your blood vessels under intense pressure and can eventually lead to a blood vessel bursting (a haemorrhage).

AVMs affect less than one in 100 people in the UK. However, you may not even realise you have one. This is because it's usually something you're born with and doesn’t cause any symptoms. Some people may have symptoms such as headaches and seizures, but this is rare.

If your doctor finds out that you have an AVM, he or she may recommend surgery to remove the malformed blood vessels. Other treatments involve blocking the blood vessels that make up the AVM with a glue material (embolisation), or destroying the AVM with focussed radiation beams (gamma knife surgery). This will help to reduce your risk of stroke.
 

Further information

The Stroke Association
0303 3033 100
www.stroke.org.uk

Sources

•    Factsheet 25: Haemorrhagic stroke. The Stroke Association. www.stroke.org.uk, published September 2009
•    Stroke information. The Stroke Association. www.stroke.org.uk, accessed 17 November 2010
•    Types of stroke. Chest Heart & Stroke Scotland. www.chss.org.uk, published 7 September 2010
•    Personal communication, Dr Ahamad Hassan, Consultant Neurologist and Stroke Physician, Spire Leeds Hospital, 5 January 2011
•    Stroke and TIA. Clinical Knowledge Summaries. www.cks.nhs.uk, published February 2009
•    Stroke: Act F.A.S.T Awareness Campaign. Department of Health. www.dh.gov.uk, published 9 February 2009
•    Stroke (CVA). The Merck Manuals. www.merck.com/mmhe, published November 2007
•    Ischemic stroke. The Merck Manuals. www.merck.com/mmhe, published November 2007
•    Stroke, Hemorrhagic. eMedicine. www.emedicine.medscape.com, published 17 June 2010
•    Simon C, Everitt H, van Dorp F. Oxford handbook of general practice. 3rd ed. Oxford: Oxford University Press, 2010:570–71
•    Conditions NCCfC. Stroke: National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: Royal College of Physicians, 2008:1–123
•    Stroke rehabilitation. The Merck Manuals. www.merck.com/mmhe, published February 2009
•    Joint Formulary Committee, British National Formulary. 60th ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2010
•    Subarachnoid hemorrhage. eMedicine. www.emedicine.medscape.com, published December 2010
•    Treadwell SD, Robinson TG. Cocaine use and stroke. Postgrad Med J, 2007; 83(980):389-94. doi:10.1136/pgmj.2006.055970
•    Cocaine (Neurology). eMedicine. http://emedicine.medscape.com, published 22 January 2010
•    Vascular malformations of the brain. Brain & Spine Foundation Online. www.brainandspine.org.uk, published 20 December 2010
•    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 20 December 2010

Related topics

•    Cervical artery dissection
•    Ischaemic stroke
•    Stroke
•    Transient ischaemic attack (TIA)

 

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