Haemorrhagic stroke

About haemorrhagic stroke

A haemorrhagic stroke happens when a blood vessel bursts and bleeds into your brain (a haemorrhage). The blood puts pressure on your brain and damages it.

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 14 people out of every 100 who have a stroke have a haemorrhagic stroke. The condition mostly affects older people, but can happen at any age. The symptoms tend to be more severe than those caused by ischaemic stroke (see our frequently asked questions for more information).

Types of haemorrhagic stroke

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 (this is formed by two membranes that cushion your brain from the bones of your skull).

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 ‘FAST’ test. FAST stands for:

  • face
  • arm
  • speech
  • time to call 999

This involves checking for any one of the three main symptoms of stroke – facial weakness, arm weakness or speech problems. If you notice that someone has one or more of these symptoms, you should call for emergency help straight away.

Other symptoms of haemorrhagic stroke may include:

  • a very severe, sudden headache
  • losing consciousness
  • vomiting
  • a stiff neck
  • numbness, weakness or inability to move your face, arm or leg on one side of your body
  • feeling dizzy and having vertigo
  • being sensitive to light
  • feeling restless and confused (delirious)
  • seizures (fits)

If you suspect that you or someone you’re with is having a stroke, call for emergency help immediately.

Complications of haemorrhagic stroke

Haemorrhagic stroke can be very severe and cause lasting damage or even be fatal. Complications of stroke may include:

  • weakness or paralysis, often on one side of your body
  • 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
  • changes in your personality and behaviour

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

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

  • bed sores (pressure ulcers)
  • deep vein thrombosis (DVT) – 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)

Causes of haemorrhagic stroke

The greatest risk factor for haemorrhagic stroke is having high blood pressure – it’s a factor in about two-thirds of all haemorrhagic strokes. If you have high blood pressure, there is more strain on your smaller blood vessels so they are more likely to burst. You’re more at 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 haemorrhagic stroke as you get older. Other factors that may increase your risk of haemorrhagic stroke include the following.

  • Swelling of an artery in your brain (intracranial aneurysm). This can weaken your artery wall and the aneurysm may burst. An aneurysm can be caused by high blood pressure or genetic factors.
  • A condition called cerebral amyloidosis can lead to a build-up of a protein called amyloid in the blood vessels in your brain. This can damage your blood vessels meaning that they may burst and cause bleeding.
  • Abnormalities in the way that blood vessels have formed in your brain (arteriovenous malformation or a cavernoma). See our frequently asked questions for more information.
  • Anything that increases your tendency to bleed. This can include having treatment with an anticoagulant medicine that reduces your blood’s ability to clot (for example, 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 to find out what type of stroke you had and which part of your brain has been 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 (for example, a CT or MRI) as soon as possible. This will help to find out if your stroke happened because of a bleed or a blocked artery.

If your doctor thinks you had a subarachnoid haemorrhage, you may need a lumbar puncture to check this if your brain scan doesn’t show any bleeding. 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.

If this confirms that you have had a haemorrhagic stroke, you may go onto have an angiogram (a test that uses an injection of a special dye into your blood vessels to make them clearly visible on X-rays or a CT scan) to find out where exactly the bleeding is in your brain. However, this isn’t always necessary.

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 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 move around as soon as you’re able. If you can’t move, you will regularly be helped to turn in your bed, to reduce your risk of getting bed sores and DVT.

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 have 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. This will allow your blood to clot and help stop further bleeding in your brain.

You may also have some of the following medicines.

  • Anticonvulsants are used 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 sometime 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 helps 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 (a condition known as hydrocephalus). If this happens, your doctor may suggest you have a drain inserted to remove the excess fluid.

If you have had an intracerebral haemorrhage in the back part of your brain (cerebellum) or near to the surface, you may need surgery to drain away the blood. However, this isn't suitable for everyone and it’s also possible to treat these without surgery.

If you have had a subarachnoid haemorrhage caused by an intracranial aneurysm, you may need surgery to reduce your risk of further bleeding. There are different operations that you may have. The most common is endovascular coiling. In this procedure, your surgeon passes a tube through a small cut in your groin into an artery and up it 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 which your surgeon opens up your skull to reach the aneurysm and puts 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

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

Stroke recovery can be difficult to predict. You may find you make most of your recovery in the early weeks and months following the stroke, but recovery can continue after this time and you may carry on improving for years afterwards.

A team of health professionals that may include physiotherapists, speech and language therapists, occupational therapists, ophthalmologists and psychologists, as well as doctors and nurses will work out a rehabilitation programme for you. This will be designed around your particular needs and will aim to help you in the long term so that you can stay as independent as possible.

Is haemorrhagic stroke more serious than ischaemic stroke?

Answer

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 to your brain and your recovery afterwards will be different to that of anyone else who has any type of stroke. For example, both haemorrhagic and ischaemic strokes can be fatal for some people, whereas others can recover well and adapt to manage 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 you recognise the symptoms of stroke. Check for these using the ‘FAST’ test. This stands for:

  • face – facial weakness
  • arm – arm weakness
  • speech – problems speaking
  • time to call 999

If someone has one or more of these symptoms, call for emergency help immediately.

How does cocaine cause a haemorrhagic stroke?

Answer

The exact way in which cocaine causes stroke isn't fully understood. However, if you use cocaine, you may be at an increased risk of haemorrhagic stroke.

Explanation

Cocaine causes blood vessels to constrict (narrow), which can slow down or stop blood flow through them. This is called a ‘spasm’ and can weaken your blood vessels and make them more likely to burst. Taking the drug can also lead to a sudden, temporary rise in blood pressure, which increases your risk of 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. However, they can lead to symptoms such as headaches and seizures (fits).

Explanation

Usually, 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 of weakened blood vessels. Over time, the pressure of the blood in the tangle can eventually lead to a blood vessel bursting (a haemorrhage).

It’s thought that AVMs affect about one in 1,000 people. However, you may not even realise you have one 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 it. Other treatments involve blocking the blood vessels that make up the AVM with a glue material (embolisation), or destroying the AVM with focused radiation beams. This will help to reduce your risk of stroke.