Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue.

See also:

• Cerebral aneurysm
• Deep intracerebral hemorrhage
• Hypertensive intracerebral hemorrhage
• Intracerebral hemorrhage
• Lobar intracerebral hemorrhage
• Subarachnoid hemorrhage

Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly. Bleeding irritates the brain tissue, causing swelling. Bleeding collects into a mass called a hematoma. Bleeding also increases pressure on the brain and presses it against the skull.

Hemorrhagic strokes are grouped according to location of the blood vessel:

• Intracerebral hemorrhage: Bleeding in the brain
• Subarachnoid hemorrhage: Bleeding in the area between the brain and the thin tissues that cover the brain

Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls until they break.

Other causes of hemorrhagic stroke include:

• Aneurysms, which create a weak spot in an artery wall, which can eventually burst
• Abnormal connections between arteries and veins, such as an arteriovenous malformation (AVM)
• Cancer, particularly cancer that spreads to the brain from distant organs such as the breast, skin, and thyroid
• Cerebral amyloid angiopathy, a build up of amyloid protein within the artery walls in the brain, which makes bleeding more likely
• Conditions or medications (such as aspirin or Warfarin) that can make you bleed excessively
• Illicit drugs, such as cocaine

The symptoms vary depending on the location of the bleed and the amount of brain tissue affected. Symptoms usually develop suddenly, without warning, and often during activity. They may come and go (be episodic) or slowly get worse over time.

Symptoms may include:

• Change in alertness (level of consciousness)
  • Apathetic
  • Coma
  • Lethargy
  • Sleepiness
  • Stupor
  • Unconsciousness
  • Withdrawn
• Difficulty speaking or understanding others
• Difficulty swallowing
• Difficulty writing or reading
• Headache
  • Occurs when lying flat
  • Wakes you up from sleep
  • Gets worse when you change positions or when you bend, strain, or cough
  • Starts suddenly
• Loss of coordination
• Loss of balance
• Movement changes, usually on only one side of the body
  • Difficulty moving any body part
  • Loss of fine motor skills
• Nausea or vomiting
• Seizure
• Sensation changes, usually on only one side of the body
  • Decreased sensation
  • Numbness or tingling
• Weakness of any body part
• Vision changes
  • Decreased vision
  • Loss of all or part of vision

A neurologic exam is almost always abnormal. The patient may look drowsy and confused. An eye examination may show abnormal eye movements and changes in the back of the eye. The patient may have abnormal reflexes. However, these findings do not necessarily mean a person is having a brain hemorrhage, and could be due to another medical condition.

A CT scan of the brain is the most important test used to confirm a brain hemorrhage. It should be done without delay.

A brain magnetic resonance imaging (MRI) scan can be done later to better understand what caused the bleeding.

Conventional angiography may be done in some cases to identify aneurysms or an arteriovenous malformation, although CT and MRI are more often used.

Other tests may include:

• Complete blood count (CBC)
• Blood clotting studies --prothrombin time (PT) and partial thromboplastin time (PTT)
• CSF (cerebrospinal fluid) exam

Hemorrhagic stroke requires prompt medical attention. It can develop quickly into a life-threatening situation. Goals of treatment are to:

• Save the person's life
• Relieve symptoms
• Repair the cause of bleeding
• Prevent complications
• Start rehabilitation therapy as soon as possible

IMMEDIATE TREATMENT IN THE HOSPITAL

Treatment is ideally given in a hospital's intensive care unit (ICU), where complications can immediately be detected. The health care team will pay careful attention to breathing because sometimes bleeding in the brain can cause breathing to stop or become irregular.

A person having a hemorrhagic stroke may be unable to protect their airway when they cough or sneeze because of decreased alertness (impaired consciousness). Saliva or other secretions may go "down the wrong pipe," which may cause potentially serious lung problems such as aspiration pneumonia. A breathing tube may needed to treat or prevent these problems.

Treatment may involve:

• Carefully controlling blood pressure, which can be too high or too low
• Drugs to control brain swelling
• Medications to relief headaches (but should be used with caution because they may reduce alertness and give the wrong impression that the patient is getting worse)
• Seizure medications such as phenytoin

The patient will need to rest in bed and avoid activities that may increase the pressure in the head (increased intracranial pressure), such as:

• Bending
• Lying flat
• Sudden position changes
• Straining during bowel movement (stool softeners or laxatives may be prescribed)

Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. These may be given through a vein ( intravenously) or a feeding tube in the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

SURGERY

Sometimes, surgery is needed to save the patient's life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. For example, a hemorrhage due to an aneurysm or AVM requires special treatment (See: Aneurysm or AVM)

For other types of bleeding, removal of the hematoma may occasionally be needed, especially when bleeding occurs in the back of the brain.

One common problem related to brain bleeding is hydrocephalus, which is the build up of fluid within the brain. A procedure called ventriculostomy may be needed to drain the fluid.

LONG-TERM TREATMENT

The goal of long-term treatment is to help the patient recover as much function as possible and prevent future strokes. The recovery time and need for long-term treatment differs from person to person. Depending on the symptoms, rehabilitation may include:

• Occupational therapy
• Physical therapy
• Speech therapy

Therapies such as repositioning and range-of-motion exercises can help prevent complications related to stroke, such as infection and bed sores. Those who have had a stroke should try to remain as active as physically possible.

Alternative forms of communication such as pictures, verbal cues, and other techniques may be needed in some cases.

Sometimes, urinary catheterization or bladder and bowel control programs may be needed to control incontinence.

A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show indifference or lack of judgment, which increases the need for safety precautions.

Caregivers may need to show the person pictures, repeatedly demonstrate how to perform tasks, or use other communication strategies, depending on the type and extent of the language problems.

In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet medical needs.

Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety).

Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.

Legal advice may be appropriate. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of a person who has had a stroke.

Hemorrhagic stroke is less common but more frequently deadly than ischemic stroke.

Recovery may occur over time as other areas of the brain take over functioning for the damaged areas. Death is possible, and may quickly occur despite prompt medical treatment.

• Decreased social interaction
• Decreased ability to function or care for self
• Decreased life span
• Difficulty communicating
• Joint contractures
• Muscle spasticity
• Permanent loss of cognitive or other brain functions (dementia)
• Permanent loss of movement or sensation of one or more parts of the body
• Pressure sores due to lack of movement
• Urinary and respiratory tract infections

A hemorrhagic stroke, or "brain attack," is a medical emergency.

Go to the emergency room or call 911 if other symptoms of a stroke develop. Emergency symptoms include:

• Difficulty breathing
• Loss of ability to move or swallow
• Loss of consciousness
• Seizures
• Sudden loss of sensations
• Sudden change in mental state

Call your health care provider if severe headache with nausea, vomiting, decreased vision, numbness, or tingling occurs.

Prevention is extremely important because treatment for hemorrhage-related brain injury often cannot reverse brain damage. Most cases of hemorrhagic stroke are associated with specific risk factors such as high blood pressure, smoking, or cocaine use.

Controlling blood pressure and avoiding smoking and cocaine can reduce your risk for brain bleeding. Surgery to correct blood vessel abnormalities such as aneurysms or AVMs is sometimes recommended to prevent bleeding.

Zivin JA. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 432.