A haemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds. This bleeding disrupts normal brain function, increases pressure inside the skull, and can quickly lead to permanent brain damage or death. Understanding this serious condition, recognizing its warning signs, and seeking immediate medical care can make the difference between life and death.

Understanding Haemorrhagic Stroke

A haemorrhagic stroke happens when a blood vessel inside or on the surface of the brain breaks open and bleeds. The term “haemorrhage” simply means bleeding inside the body. When this bleeding occurs in the brain, it prevents brain tissue from receiving the oxygen and nutrients it needs to survive. At the same time, the leaked blood builds up and creates extra pressure inside the skull, which can damage or kill brain cells.^[1]

This type of stroke is different from the more common ischaemic stroke, where a blood clot blocks an artery and cuts off blood flow to the brain. While haemorrhagic strokes are less common, they tend to be more dangerous and cause more severe symptoms that worsen rapidly. Without fast medical attention, these strokes often result in permanent brain damage and can be fatal.^[1]

There are two main types of haemorrhagic stroke, classified by where the bleeding occurs. An intracerebral haemorrhage happens when a blood vessel bleeds directly into the brain tissue, sometimes deep inside the brain. This is the most common type of haemorrhagic stroke, accounting for about two-thirds of all cases. A subarachnoid haemorrhage occurs when blood leaks into the space between the brain and the protective layers of tissue that surround it. This space, called the subarachnoid space, normally contains fluid that cushions the brain from injury. Subarachnoid haemorrhage is the least common type of stroke overall.^[6]

How Common Are Haemorrhagic Strokes

Haemorrhagic strokes account for approximately 10 to 15 percent of all strokes, making them less common than ischaemic strokes. Despite being less frequent, they are associated with higher rates of severe disability and death.^[4] In the United Kingdom, around 15 percent of strokes are haemorrhagic.^[6]

These strokes tend to affect men more often than women. Age is also an important factor, with people aged 65 and older facing higher risk. The risk continues to increase as people get older.^[4]

Among specific types of haemorrhagic stroke, brain arteriovenous malformations, or AVMs, are rare. These abnormal tangles of blood vessels occur in only 10 to 18 per 100,000 adults, and both men and women are affected equally.^[2]

What Causes Haemorrhagic Stroke

The most common cause of haemorrhagic stroke is high blood pressure, also called hypertension. When blood pressure remains very high over a long period, it damages the walls of blood vessels in the brain. This damage causes changes in the arteries, including degeneration, breakage, and the formation of tiny weak spots called microaneurysms, also known as Charcot-Bouchard aneurysms. These weakened vessels can eventually rupture and bleed.^[3]

A brain aneurysm is another major cause of haemorrhagic stroke. An aneurysm develops when a weak spot forms on the wall of an artery in the brain, often where the artery branches out. As blood flows past this weak spot, pressure increases, causing the artery to bulge outward like a balloon. Over time, the walls of the aneurysm become thinner and weaker until they eventually burst, flooding the space around the brain with blood.^[4]

An arteriovenous malformation, or AVM, is an abnormal tangle of blood vessels that forms in the brain. Normally, blood flows from arteries into tiny capillaries, which slow the blood down before it moves into veins at low pressure. In an AVM, the capillaries are missing, so high-pressure blood from the arteries flows directly into the softer, weaker veins. This extra pressure causes wear and tear, which can lead to bleeding and stroke. AVMs are rare and can rupture at any age.^[8]

Other conditions that can cause haemorrhagic stroke include brain tumours, which can weaken blood vessel walls, and moyamoya disease, a rare condition where arteries at the base of the brain gradually narrow or become blocked. This forces blood to flow through smaller, more fragile arteries that are more likely to burst. Head injuries from trauma can also cause bleeding in the brain, although this is not always referred to as a stroke.^[1][8]

Cerebral amyloid angiopathy, or CAA, is an important cause of bleeding in older adults. This condition happens when abnormal protein deposits called amyloid build up in the walls of small and medium-sized arteries in the brain. Over time, these deposits weaken the blood vessels, leading to bleeding, especially in the outer layers of the brain. CAA can cause small, symptomless “microbleeds” and increases the risk of a larger haemorrhage that can result in stroke-like symptoms.^[3][4]

Risk Factors for Haemorrhagic Stroke

Several factors increase the likelihood of experiencing a haemorrhagic stroke. The most significant is chronic high blood pressure, especially if it is poorly controlled or remains high for many years. Maintaining healthy blood pressure levels is one of the most effective ways to prevent haemorrhagic stroke.^[8]

Lifestyle habits play a major role in stroke risk. Smoking and tobacco use damage blood vessels and contribute to the development of aneurysms. Heavy alcohol consumption also increases risk. The use of illegal drugs, particularly cocaine and amphetamines, can cause sudden spikes in blood pressure and lead to bleeding in the brain.^[4]

Certain medical conditions and treatments also raise the risk. People who take blood-thinning medications, also called anticoagulants, have a higher chance of bleeding if a blood vessel ruptures. Bleeding disorders, such as haemophilia or sickle cell anaemia, affect the blood’s ability to clot properly and can lead to haemorrhage. Liver disease can interfere with the production of clotting factors, making bleeding more likely.^[4][5]

Other risk factors include an unhealthy diet, high cholesterol, obesity, and having a family history of stroke or aneurysms. Brain infections, such as endocarditis (an infection of the heart valves), can also increase the risk of bleeding.^[4][8]

Recognizing the Symptoms

The symptoms of a haemorrhagic stroke often appear suddenly and can worsen very quickly. One of the most common and distinctive symptoms is a severe, sudden headache. People who experience a subarachnoid haemorrhage often describe this as a “thunderclap headache,” which feels like being hit on the head and is the worst pain they have ever experienced. Even if this type of headache goes away on its own or with painkillers, it requires immediate emergency care.^[1][6]

Other symptoms depend on where the bleeding occurs in the brain but can include weakness or paralysis on one side of the body, numbness, or loss of sensation. Vision problems are common, such as double vision, blurry vision, or sudden vision loss in one or both eyes. Some people experience confusion, memory problems, or difficulty understanding what others are saying.^[1]

Speech difficulties are another warning sign. This might include slurred or garbled speech, known as dysarthria, or trouble finding the right words, called aphasia. Loss of balance, dizziness, or problems with coordination can also occur. Neck stiffness, nausea, and vomiting are particularly common with subarachnoid haemorrhage. In severe cases, people may have seizures, lose consciousness, or fall into a coma.^[1][6]

To recognize stroke symptoms quickly, remember the acronym BE FAST. B stands for Balance: watch for a sudden loss of balance. E stands for Eyes: look for sudden vision loss or changes. F stands for Face: ask the person to smile and check if one side of the face droops. A stands for Arms: ask the person to raise both arms and see if one drifts downward or feels weak. S stands for Speech: listen for slurred speech or difficulty speaking. T stands for Time: time is critical, so call emergency services immediately if you notice any of these signs.^[1]

How Doctors Diagnose Haemorrhagic Stroke

When a stroke is suspected, doctors work quickly to diagnose the condition so treatment can begin as soon as possible. The first step is usually a physical examination and questions about the person’s symptoms and medical history. Because haemorrhagic stroke can cause confusion or unconsciousness, family members may need to provide information about the patient’s health, medications, and any history of high blood pressure or bleeding disorders.^[4]

Imaging tests are essential to confirm a haemorrhagic stroke and determine where the bleeding is located. A computed tomography, or CT scan, is usually the first test performed because it is fast and can quickly show bleeding in the brain. This scan uses X-rays and a computer to create detailed images of the brain from multiple angles.^[3]

In some cases, doctors may use magnetic resonance imaging, or MRI, which uses magnets and radio waves to create detailed pictures of soft tissues in the brain. An MRI can sometimes provide more detailed information than a CT scan, particularly for smaller bleeds or other brain abnormalities. Other tests, such as an electroencephalogram, or EEG, or a lumbar puncture (also called a spinal tap), may be used to confirm the diagnosis or rule out other conditions.^[5]

Treatment Approaches

The immediate treatment of haemorrhagic stroke focuses on stopping the bleeding, reducing pressure inside the skull, and stabilizing the patient’s vital signs. This often requires urgent medical intervention and close monitoring in a hospital setting. Treatment begins with ensuring the patient can breathe properly. If someone has a decreased level of consciousness, doctors may perform endotracheal intubation, which involves placing a tube down the throat to help with breathing.^[11]

Controlling blood pressure is a critical part of treatment. If blood pressure is too high, it can worsen the bleeding, but lowering it too quickly can reduce blood flow to the brain. Doctors carefully manage blood pressure with medications to find the right balance. In some cases, medications are used to reduce pressure inside the skull or to stop seizures if they occur.^[11]

Surgery may be necessary in certain situations. If the bleeding is large or causing significant pressure on the brain, doctors may perform a craniotomy, which involves opening the skull to remove the blood and relieve pressure. For smaller bleeds, doctors may use less invasive techniques. If the stroke was caused by an aneurysm, surgeons may place a tiny clip at the base of the aneurysm to stop blood flow to it and prevent it from bursting again. Another option is to thread a small tube, called a catheter, through the blood vessels to the aneurysm and fill it with tiny coils or other materials to block blood flow.^[14]

If the stroke was caused by an arteriovenous malformation, surgeons may remove the AVM if it is accessible and not too deep in the brain. In some cases, doctors use stereotactic radiosurgery, a technique that uses focused beams of radiation to shrink or destroy the abnormal blood vessels without making an incision.^[14]

After the initial emergency treatment, rehabilitation plays a key role in helping people recover lost abilities and regain independence. Rehabilitation may include physical therapy to improve mobility and strength, occupational therapy to relearn everyday tasks, speech therapy to improve communication and swallowing, and cognitive therapy to address memory and problem-solving skills. The type and duration of rehabilitation depend on the severity of the stroke and the individual’s specific needs.^[20]

Preventing Haemorrhagic Stroke

While there is no guaranteed way to prevent haemorrhagic stroke, adopting a healthy lifestyle can significantly reduce the risk. The most important step is managing high blood pressure. This may involve taking prescribed medications regularly, reducing salt intake, maintaining a healthy weight, exercising regularly, and managing stress.^[8]

Quitting smoking and avoiding tobacco products is essential, as smoking damages blood vessels and increases the risk of aneurysms and stroke. Limiting alcohol consumption is also important, as excessive drinking can raise blood pressure and weaken blood vessels. Avoiding illegal drugs, particularly cocaine and amphetamines, is critical because these substances can cause sudden, dangerous increases in blood pressure.^[8]

Following a heart-healthy diet that is rich in fruits, vegetables, whole grains, and lean proteins can help maintain healthy blood vessels and reduce the risk of stroke. Managing cholesterol levels through diet and, if necessary, medication is also beneficial. Regular physical activity, such as walking, swimming, or cycling, helps maintain a healthy weight, lowers blood pressure, and improves overall cardiovascular health.^[8]

If you have known risk factors, such as a family history of aneurysms or a diagnosed AVM, it is important to work closely with your doctor. Regular check-ups and monitoring can help detect problems early and allow for preventive treatment before a stroke occurs. If you take blood-thinning medications, your doctor will monitor you closely to balance the benefits of the medication with the risk of bleeding.

What Happens in the Brain During a Haemorrhagic Stroke

To understand how a haemorrhagic stroke affects the body, it helps to think of the brain as a city with a complex network of roads. Blood vessels act like these roads, carrying vital supplies—oxygen and nutrients—to different neighbourhoods, which represent different regions of the brain. When a blood vessel ruptures, it is like a water main bursting. The leaked blood not only deprives the surrounding area of essential supplies but also causes flooding, which damages everything nearby.^[1]

When a blood vessel breaks in the brain, several harmful processes begin at once. First, the bleeding disrupts normal blood circulation, preventing brain cells in the affected area from receiving the oxygen and nutrients they need to survive. Without oxygen, brain cells begin to die within minutes. Second, the leaked blood accumulates and creates extra pressure inside the skull. Because the skull is a closed, rigid space, there is no room for the extra volume of blood. This increased pressure, called intracranial pressure, squeezes the brain tissue and can cause further damage or death of brain cells.^[1]

The blood itself is also toxic to brain tissue. When blood leaks into the brain, it releases chemicals and triggers inflammation, which can weaken and kill brain cells in the area surrounding the bleed. The location of the bleeding determines which brain functions are affected. For example, bleeding in the area that controls movement can cause weakness or paralysis on one side of the body, while bleeding in the area responsible for speech can lead to difficulty speaking or understanding language.^[12]

In cases of chronic high blood pressure, the arteries undergo long-term damage. The walls of the arteries break down, smooth muscle fragments, and weak spots develop. Small branches of arteries, which are only 50 to 700 micrometres in diameter, can have multiple rupture sites. These tiny ruptures are often associated with layers of clotted blood, which shows that the bleeding happened in stages.^[3]

When an aneurysm bursts, blood floods into the subarachnoid space, the area between the brain and the protective membranes that surround it. This sudden increase in blood and pressure can cause widespread damage and is one of the reasons why subarachnoid haemorrhages are particularly dangerous. The rapid expansion of the haemorrhage often leads to a sudden deterioration in consciousness and neurological function, which is why early diagnosis and treatment are so critical.^[3]