Call the Stroke Helpline: 0303 3033 100 or email: [email protected] Bleeding in the brain: haemorrhagic stroke A stroke due to bleeding in or around the brain is known as a haemorrhagic stroke. This guide explains the different types of stroke caused by bleeding, and how they are diagnosed and treated. What is a haemorrhagic stroke? 1. Bleeding within the brain If blood leaks from a blood vessel in When an artery inside the brain bursts it is or around the brain, this is called a called an intracerebral haemorrhage. About haemorrhagic stroke. You may also hear it 10% of all strokes are of this type. The called a brain haemorrhage or a brain bleed. blood leaks out into the brain tissue at high pressure, killing brain cells and causing brain In the UK, around 15% of strokes are swelling. haemorrhagic (due to a bleed), and about 85% are ischaemic (due to a blockage to the 2. Bleeding on the surface of the blood supply in the brain). brain Haemorrhagic stroke tends to affect The brain sits inside a fluid-filled cushion of younger people than ischaemic stroke, and membranes that protects it from the skull, is most common in people aged between called the subarachnoid space. If blood 45 and 70. Most strokes in the UK happen vessels near the surface of the brain burst over the age of 70. and blood leaks into the subarachnoid space, this is called a subarachnoid haemorrhage There are two main types of haemorrhagic (SAH). stroke: SAH accounts for around 5% of all strokes, 1. Bleeding within the brain: called and it is most often caused by a burst an intracerebral haemorrhage, or aneurysm (a bulging of the wall of an artery – intracranial haemorrhage (ICH). see later in this guide for more information). 2. Bleeding on the surface of the brain: Subarachnoid haemorrhage (SAH) can run called a subarachnoid haemorrhage in families. If you have had an SAH and are (SAH). concerned that this might affect your own family, speak to your GP. They can help you understand the causes of your stroke and the risks for your family members. For more information visit stroke.org.uk 1 Bleeding in the brain: haemorrhagic stroke Symptoms • Sudden memory loss or confusion, and dizziness or a sudden fall. Some people get a sudden, severe headache, or a very stiff neck with vomiting • A sudden, severe headache. during a haemorrhagic stroke. But the main signs of a haemorrhagic stroke can be any of If you spot any of these signs of a stroke, those in the FAST test. don’t wait. Call 999 straight away. FAST test What causes a haemorrhagic stroke? \ Face Can the person smile? Has High blood pressure their face fallen on one side? The main cause of haemorrhagic stroke is Arms damage to the very small arteries inside the Can the person raise both brain, which is often related to high blood arms and keep them there? pressure (hypertension). This process, called Speech ’small vessel disease’, makes the small Can the person speak clearly arteries in the brain more prone to bleeding. and understand what you say? Is their speech slurred? Cerebral amyloid angiopathy (CAA) Time This is a common type of small vessel If you see any of these three signs, it’s time to call 999. disease where a protein called amyloid builds up inside the small blood vessels near the surface of the brain. The resulting damage can cause a vessel to tear, causing bleeding. The FAST test helps to spot the three most common symptoms of stroke. But there This condition is more common among older are other signs that you should always take people, and older people with dementia. seriously. These include: Although there are no proven treatments for CAA, controlling blood pressure can help • Sudden weakness or numbness on one reduce the risk of bleeding in the brain. side of the body, including legs, hands or feet. Magnetic resonance imaging (MRI) scans have shown that CAA is present in patients • Difficulty finding words or speaking in with bleeds in specific areas of the brain near clear sentences. to the surface (called lobar areas), known as lobar intracerebral haemorrhage. Smaller • Sudden blurred vision or loss of sight in bleeds, which can be detected on MRI scans, one or both eyes. are called “microbleeds”. Microbleeds are a common feature of CAA and often appear without symptoms. 2 Call the Stroke Helpline on 0303 3033 100 Bleeding in the brain: haemorrhagic stroke Burst aneurysm Blood-thinning medication An aneurysm is a weak spot on an artery Medication to lower the risk of blood clots that has ballooned out. Artery walls are causes a higher risk of bleeding in the brain. usually thick and strong, but the walls of an However, your risk of stroke is carefully aneurysm are thin and weak because they monitored when you’re taking blood- have been stretched. Aneurysms most thinning medications, including antiplatelet commonly occur in the main artery leading agents and anticoagulants. away from the heart (the abdominal aorta), and the brain. People using these types of drug have their suitability assessed by a doctor, Some brain aneurysms are present from who looks carefully at the benefits of the birth. There are also a number of risk factors blood-thinning medication and the risks that increase your chances of developing of bleeding. You should always discuss any a brain aneurysm. These include smoking, concerns about your medication with your high blood pressure, a family history of doctor. aneurysms, using cocaine, and having a genetic kidney condition called autosomal Illegal drugs dominant polycystic kidney disease (ADPKD). Cocaine can raise the risk of a haemorrhagic stroke in the days after using it. Others, like A brain aneurysm doesn’t usually cause any cannabis and khat, are associated with an symptoms unless it bursts, but people may increased risk and higher death rate from experience pain on one side of the face or stroke. around an eye, loss of vision or headaches. How are strokes due to bleeding A burst aneurysm is the most common diagnosed? cause of a subarachnoid haemorrhage. After a haemorrhage an aneurysm can seal itself, When someone is taken to hospital with a but there is a risk of it bleeding again. suspected stroke, a brain scan should be carried out urgently and within one hour Abnormal blood vessels of arriving in hospital. The scan could be either a computed tomography (CT) or MRI Rarely, people are born with abnormalities in scan. The brain scan will show if a stroke has their blood vessels. They are called vascular happened, and whether it was caused by a malformations, and are tangles of blood blockage or by bleeding. vessels or enlarged blood vessels. To help diagnose SAH, a lumbar puncture Cavernous malformation is one type of might be carried out as well as a brain scan. vascular malformation. It is a cluster of This is a procedure to remove a sample of enlarged blood vessels. Many people with the cerebrospinal fluid that bathes the brain this condition do not experience any ill and spinal cord. It will show if any blood has effects, but if the thin vessel walls break it leaked into this fluid. can cause bleeding in the brain. For more information visit stroke.org.uk 3 Bleeding in the brain: haemorrhagic stroke A digital subtraction angiogram (or catheter given to treat it. See our guide ‘Epilepsy after angiogram) uses X-rays to locate the burst stroke’ for more information. blood vessel. A fine tube called a catheter is put into an artery, usually in the groin. A Surgery to relieve pressure on the liquid called a contrast, or dye, is injected brain into the blood. The contrast makes the blood vessels show up on an X ray and reveals Emergency surgery is sometimes needed to where the bleeding occurred. remove blood, to relieve any pressure that has built up, or to repair the blood vessels. To help diagnose the cause of intracerebral This is usually done with a procedure called a haemorrhage you might also have further CT craniotomy. This operation should be carried or MRI scans, including special scans of the out by a neurosurgeon. blood vessels that do not require a catheter (non-invasive angiography). During the operation, a small piece of skull is cut away so the surgeon can access the How will I be treated? cause of the bleeding. They can then repair any damaged blood vessels and ensure Medication there are no blood clots that could restrict the flow of blood in your brain. If a blood clot When admitted to hospital with a has formed, it may be removed. After the brain haemorrhage, if you are taking bleeding has stopped, the piece of skull can anticoagulants, you will be immediately be replaced. prescribed medication to reverse those effects. If you are also diagnosed with high With any type of bleed in or around the brain, blood pressure, you will be given medication the escaping blood can sometimes alter to bring it down. the normal flow of cerebrospinal fluid. This can result in a build-up of fluid around the After an SAH a lack of blood supply to the brain called hydrocephalus. This can cause brain can lead to further brain damage, called pressure and pain, and if left untreated, can cerebral ischaema. To prevent this, you may cause damage to the brainstem (the base be given a drug called nimodipine for about of the brain which controls most of the three weeks.