Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue.
Brain bleeding; Brain hemorrhage; Stroke - hemorrhagic; Hemorrhagic cerebrovascular disease
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:
Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls until they break.
Other causes of hemorrhagic stroke include:
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:
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.
Other tests may include:
Hemorrhagic stroke requires prompt medical attention. It can develop quickly into a life-threatening situation. Goals of treatment are to:
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:
The patient will need to rest in bed and avoid activities that may increase the pressure in the head (increased intracranial pressure), such as:
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.
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.
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:
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.
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:
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.