Stroke And Hemorrhage: What's The Connection?

A stroke that leads to a haemorrhage (excess blood in the brain) is called a haemorrhagic stroke. This occurs when a weakened vessel ruptures and bleeds into the brain or the surrounding area. Haemorrhagic strokes account for about 13% of all stroke cases and can be either intracerebral (within the brain) or subarachnoid (between the brain and the membranes covering it). They can be life-threatening and require immediate medical attention.

Intracerebral haemorrhage

ICH occurs when a weakened blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. This can happen due to various reasons, including chronic hypertension, amyloid angiopathy, anticoagulation medication, vascular malformations, aneurysms, and head trauma. The blood accumulates and compresses the surrounding brain tissue, leading to a sudden increase in mass within the brain. This compression can cause damage to the brain tissue, resulting in a range of neurological symptoms.

The risk factors for ICH include advanced age (over 55 years), male gender, non-white ethnicity, family history of stroke, high blood pressure, use of blood thinners, alcohol and drug use, and underlying medical conditions such as liver disease, bleeding disorders, and tumours.

The symptoms of ICH usually come on suddenly and can vary depending on the location of the bleed. Common symptoms include sudden onset of a severe headache, nausea, vomiting, lethargy or confusion, weakness or numbness in the face, arm or leg, usually on one side, and loss of consciousness.

The diagnosis of ICH is made through imaging techniques such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and angiography. Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and relieving the pressure on the brain. This can be achieved through medical or surgical interventions, depending on the location and severity of the bleed.

The prognosis for ICH can vary, with approximately 70% of patients experiencing long-term deficits. The mortality rate is high, with up to 50% of patients dying within 30 days of the initial insult. Early and aggressive medical management has been shown to improve outcomes by reducing the risk of rebleeding and hematoma expansion.

Subarachnoid haemorrhage

The most common cause of subarachnoid haemorrhage is the rupture of a weakened blood vessel or aneurysm on the surface of the brain. This can lead to bleeding into the subarachnoid space, resulting in a sudden and severe headache, often described as the "worst headache of my life". Other symptoms include nausea, vomiting, sensitivity to light, blurred or double vision, stroke-like symptoms such as slurred speech and weakness on one side of the body, and loss of consciousness or convulsions.

The treatment for subarachnoid haemorrhage involves locating the source of the bleed and surgically "clipping" it to control the bleeding and reduce pressure on the brain. This may involve endovascular coiling or direct surgical clipping of the blood vessel. Medications may also be given to prevent short-term complications and control blood pressure.

The risk factors for subarachnoid haemorrhage include excessive alcohol consumption, severe head injuries, high blood pressure, smoking, older age (over 40 or 65), and certain medical conditions such as diabetes, high cholesterol, and bleeding disorders. It is important to seek immediate medical attention if you experience any symptoms of subarachnoid haemorrhage, as early treatment is crucial for reducing the risk of long-term brain damage and improving outcomes.

Risk factors

Hemorrhagic strokes, or strokes caused by bleeding in or around the brain, have several risk factors. These risk factors can be categorized into two types: those that are specific to intracerebral hemorrhage and those that are specific to subarachnoid hemorrhage.

Intracerebral hemorrhage, or bleeding inside the brain, can be caused by:

• Blood vessel malformations, such as cerebral cavernous malformations or cerebral aneurysms.
• Arteriovenous malformation (AVM), a rare genetic condition that affects the brain and spine.
• High blood pressure (hypertension).
• Heavy alcohol use.
• Advanced age.
• Use of cocaine or amphetamines.
• Uncontrolled diabetes.
• High cholesterol.

Subarachnoid hemorrhage, or bleeding between the brain and the membranes that cover it, can be caused by:

• Having a bleeding disorder.
• Experiencing a head injury or physical trauma.
• Using blood-thinning medication.
• Having a history of heart disease, cardiovascular disease, or stroke.
• High levels of stress and anxiety.
• High alcohol consumption.
• Excess weight around the waist and abdomen.
• Cerebral amyloid angiopathy, where proteins collect in the blood vessels in the brain, increasing the risk of tears.

Symptoms

A hemorrhagic stroke is a stroke that leads to a haemorrhage, or too much blood in the brain. It can occur when a weakened vessel ruptures and bleeds into the brain or the surrounding area. There are two types of hemorrhagic strokes: intracerebral hemorrhage, which occurs within the brain, and subarachnoid hemorrhage, which occurs between the inner and outer layers of the tissue covering the brain.

Intracerebral Hemorrhage Symptoms:

• Paralysis or numbness in any part of the body
• Inability to control eye movements correctly
• Inability to move or feel
• Confusion and irritability
• Inability to speak or understand speech
• Loss of balance or coordination
• Loss of consciousness
• Sensitivity to light
• Changes in heartbeat and breathing
• Difficulty swallowing
• Headache

Subarachnoid Hemorrhage Symptoms:

• Very severe headache that starts suddenly, often described as a "thunderclap"
• Loss of consciousness
• Inability to look at bright light
• Loss of balance or coordination
• Numbness or weakness on one side of the body
• Loss of speech or difficulty understanding speech
• Confusion or loss of consciousness
• Paralysis or numbness in any part of the body
• Stiffness or pain in the neck area
• Changes in heartbeat and breathing
• Seizures

General Hemorrhagic Stroke Symptoms:

• Numbness or weakness in the arm, face, or leg
• Difficulty speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden dizziness
• Loss of balance or coordination
• Sudden, severe headache with no known cause
• Vomiting
• Nausea
• Lethargy
• Muscle pain in the neck and shoulders
• One eye pupil larger than the other

Treatment

A hemorrhagic stroke is a medical emergency that requires immediate treatment. The treatment options depend on the type, location, and severity of the stroke, as well as the patient's overall health and medical history. Here is an overview of the treatment options for hemorrhagic strokes:

Emergency Treatment

The primary goal of emergency treatment is to control the bleeding and reduce the pressure in the brain. This can involve:

• Medications to reduce blood pressure and slow down bleeding
• Counteracting the effects of blood thinners if the patient is taking any
• Repairing affected blood vessels or sealing an aneurysm
• Performing a craniotomy to relieve pressure on the brain caused by swelling
• Monitoring blood pressure closely, especially in the hours after a hemorrhagic stroke
• Preventing arteries from narrowing and going into spasm, which can damage brain tissue

Surgical Treatment

For more severe strokes, surgery may be necessary to repair the ruptured blood vessel and stop the bleeding. This can include:

• Clipping the source of the bleed
• Draining the skull to decrease pressure
• Blocking off any sources of bleeding
• Performing a "burr hole" removal of the intracerebral hemorrhage
• Removing or repairing an arteriovenous malformation (AVM)
• Clipping or coiling an aneurysm

Rehabilitation and Recovery

After the initial emergency treatment, patients typically undergo a rehabilitation program to recover as much function as possible and regain independence. This can include:

• Occupational therapy
• Physical therapy
• Speech therapy
• Medication to manage mental health impacts such as depression
• Monitoring and managing symptoms and complications
• Following a heart-healthy diet
• Quitting or avoiding smoking
• Regular exercise
• Maintaining a healthy weight
• Developing regular sleeping habits

Preventing Recurrence

It is important to control risk factors to prevent recurrent hemorrhagic strokes. This includes:

• Controlling high blood pressure
• Avoiding alcohol and drug use
• Discussing the risks of blood thinners with a doctor

Frequently asked questions