Haemorrhagic Stroke

A haemorrhagic stroke is a life-threatening medical emergency that occurs when a blood vessel in the brain ruptures and bleeds. This less common but more dangerous type of stroke requires immediate treatment, as every second counts in preventing permanent brain damage or death.

Table of contents

• What is a haemorrhagic stroke?
• Types of haemorrhagic stroke
• What causes haemorrhagic stroke?
• Warning signs and symptoms
• How is haemorrhagic stroke diagnosed?
• Treatment options
• Prevention and risk factors
• Outlook and recovery

What is a haemorrhagic stroke?

A haemorrhagic stroke happens when a blood vessel in the brain breaks or ruptures and bleeds into the surrounding brain tissue or the space around the brain.^[1] The term haemorrhage means bleeding inside the body. When this bleeding occurs in the brain, it disrupts normal blood flow and prevents the brain from getting the oxygen and nutrients it needs to survive and function properly.^[1]

The bleeding also creates extra pressure inside the skull, which can damage or kill brain cells. This makes haemorrhagic strokes particularly dangerous because they cause severe symptoms that get worse quickly.^[1] Without fast medical attention, these strokes often cause permanent brain damage and can be fatal.

Haemorrhagic strokes account for about 10 to 15 per cent of all strokes, making them less common than ischaemic strokes, which happen when a blood clot blocks an artery in the brain.^[2][4] However, haemorrhagic strokes are often more deadly and more likely to cause long-term disability in those who survive.^[4]

Types of haemorrhagic stroke

There are two main types of haemorrhagic stroke, classified by where the bleeding occurs in the brain:^[1][6]

Intracerebral haemorrhage is the most common type of haemorrhagic stroke, accounting for about two-thirds of all haemorrhagic strokes.^[6] This occurs when a blood vessel inside the brain ruptures and bleeds directly into the brain tissue, sometimes deep inside the brain.^[3] The bleeding puts pressure on the brain tissue from the inside.

Subarachnoid haemorrhage is less common, causing about one in 20 of all strokes.^[6] This type occurs when bleeding happens in the space between the brain and the thin layers of tissue covering it. This protective layer of fluid, called the subarachnoid space, helps cushion the brain from injury.^[6] When a blood vessel on the surface of the brain ruptures, blood floods this space between the skull and the brain.^[1]

What causes haemorrhagic stroke?

Several conditions can damage or break blood vessels in the brain, leading to a haemorrhagic stroke. High blood pressure, also called hypertension, is the most common cause of haemorrhagic stroke.^[1][3] This is especially true when blood pressure is very high or stays high for a long time. Long-standing high blood pressure weakens blood vessel walls over time, causing changes in the arteries that can lead to rupture.^[3]

A brain aneurysm is another common cause. An aneurysm is a weak spot on the wall of an artery within the brain, often at a location where the artery branches out. As blood passes by this weak spot, pressure increases, forming a bulge or outpouching.^[4] As the aneurysm grows, the walls become thinner and weaker, eventually leading to rupture. About half of ruptured aneurysms can lead to death.^[8]

Arteriovenous malformation, or AVM, is an abnormal tangle of blood vessels that forms in the brain. Normally, arteries carry oxygen-rich blood from the heart to the brain, and veins carry blood with less oxygen back to the heart. In an AVM, blood vessels bypass normal brain tissue and directly divert blood from arteries to veins.^[2] This abnormal connection creates a higher risk of bleeding. AVMs are rare, affecting only about 1 per cent of people, but they are a leading cause of haemorrhagic stroke in people under 45.^[4][8]

Cerebral amyloid angiopathy is an important cause of bleeding in the brain in older adults. This condition is characterized by the buildup of a protein called amyloid in the walls of blood vessels in the brain, making them more likely to rupture.^[3][4]

Other possible causes of haemorrhagic stroke include:^[1][4]

• Brain tumours
• Head injuries or trauma
• Blood-thinning medications
• Bleeding disorders
• Liver disease
• Drug abuse, particularly cocaine or amphetamines
• Smoking or heavy alcohol use
• Moyamoya disease
• COVID-19

Warning signs and symptoms

Haemorrhagic stroke symptoms often happen suddenly and can include one or more of the following:^[1][4]

• Sudden, severe headache (often described as the worst pain ever experienced)
• Thunderclap headache (feels like being hit on the head)
• Sensitivity to light
• Dizziness or vertigo
• Trouble understanding or speaking
• Slurred or garbled speech
• One-sided weakness or paralysis
• Loss of senses, such as vision, hearing or touch
• Stiff neck
• Nausea and vomiting
• Confusion or memory problems
• Loss of balance or coordination
• Seizures
• Passing out, fainting or loss of consciousness

Many, but not all, people who have a haemorrhagic stroke experience a headache. A sudden, severe headache is very likely with a subarachnoid haemorrhage but can also happen with an intracerebral haemorrhage.^[6] People describe a thunderclap headache as the worst pain they have ever had. If you have a thunderclap headache, even if it goes away by itself or with painkillers, you should call emergency services immediately.^[6]

To recognize the warning signs of stroke in yourself or a loved one, remember the acronym BE FAST:^[1]

• Balance: Watch for a sudden loss of balance
• Eyes: Look out for sudden vision loss or changes in one or both eyes
• Face: Smile and look for a droop on one or both sides of the face
• Arms: Raise both arms. If you’re having a stroke, one arm may not move, sag or be very weak
• Speech: You might slur your speech or have trouble choosing the right words
• Time: Time is critical — call emergency services immediately

A stroke is a medical emergency, and you should always call emergency services if you have any stroke symptoms.^[6] The sooner someone is diagnosed and treated, the more likely they are to survive a stroke. Every second counts.

How is haemorrhagic stroke diagnosed?

When stroke of any kind is suspected, emergency services should be called immediately. To diagnose the type of stroke a person has had, doctors will ask about medical history, perform a physical examination and order diagnostic tests.^[4] Doctors work quickly to definitively diagnose the condition so that they may begin treatment as soon as possible.

Haemorrhagic stroke can lead to sleepiness, confusion or unconsciousness, so relatives may need to provide details about a patient’s medical history. Doctors may ask if the patient has high blood pressure or a bleeding disorder and if they take blood thinners.^[4]

A computed tomography scan, or CT scan, is the initial investigation of choice for diagnosing haemorrhagic stroke.^[3] This imaging test can quickly show whether there is bleeding in the brain and help determine whether the stroke was caused by a clot (ischaemic stroke) or by bleeding (haemorrhagic stroke).^[5]

Other imaging tests may include:^[5]

• Magnetic resonance imaging (MRI)
• Electroencephalogram (EEG)
• Lumbar puncture (spinal tap)

Treatment options

Haemorrhagic stroke requires immediate treatment and can be fatal. The treatment focuses on controlling the bleeding and reducing pressure in the brain caused by the excess fluid.^[7]

Management begins with stabilization of vital signs. For patients with a decreased level of consciousness and poor airway protection, breathing support may be needed. If pressure inside the skull is elevated, doctors may use medications to help control it.^[11]

Basic life support, as well as control of bleeding, seizures, blood pressure and pressure inside the brain, are critical.^[11] Medications used in the treatment may include:^[11]

• Medicines to prevent seizures
• Blood pressure medications to reduce pressure and other risk factors of heart disease
• Medications to decrease pressure inside the brain
• Blood products or medications to help stop bleeding

Surgery may be needed in some cases. After a haemorrhagic stroke, surgery through the skull may be required to remove the blood and relieve pressure on the brain if the area of bleeding is large enough.^[14] Surgery may also be used to repair blood vessel problems associated with haemorrhagic strokes.

Surgical procedures may include:^[14]

• Surgical clipping: A surgeon places a tiny clamp at the base of an aneurysm to stop blood flow to it, which can keep the aneurysm from bursting or prevent it from bleeding again
• Surgical AVM removal: Surgeons may remove a smaller AVM if it’s located in an accessible area of the brain, eliminating the risk of rupture
• Angioplasty and stents: A balloon is inflated to expand a narrowed artery, and a stent can be inserted to support the opened artery

After the initial emergency treatment, rehabilitation can help people recover lost abilities and regain independence.^[7] Rehabilitation after a haemorrhagic stroke isn’t just about regaining physical skills — it’s also about empowering people to live a fulfilling and enjoyable life.^[20]

Prevention and risk factors

High blood pressure is the primary risk factor for haemorrhagic strokes, and maintaining healthy blood pressure levels helps prevent them.^[8] There is no way to guarantee that you won’t have a haemorrhagic stroke, but lifestyle factors can make it less likely.

Risk factors to avoid include:^[8]

• Smoking or tobacco use
• Illegal drug use
• Excessive alcohol consumption
• An unhealthy diet
• High cholesterol
• Obesity

Age (being 65 or older) is a risk factor for haemorrhagic stroke, with risk increasing as the years go by. Haemorrhagic strokes are more common among men than women.^[4]

Outlook and recovery

Haemorrhagic stroke is associated with severe illness and high death rates.^[3] Progression of haemorrhagic stroke is associated with worse outcomes. Those who survive a haemorrhagic stroke are much more likely to experience long-term disability.^[4]

Recovery can be challenging. A stroke can be overwhelming, but rehabilitation can help people learn to develop healthy coping skills to manage their stress and anxiety, improving their overall wellbeing and emotional resilience.^[20]

With prompt medical attention and personalized and dedicated rehabilitation, many people who experience a haemorrhagic stroke can regain a significant amount of function and improvement in their quality of life.^[20] Rehabilitation can help in several ways:

• Increasing mobility and independence through physical and occupational therapy
• Enhancing communication through speech therapy
• Improving cognitive function through exercises that help the brain relearn lost skills
• Reducing stress and anxiety
• Boosting confidence and self-esteem
• Reducing risk of complications