Most strokes are caused by a blockage in an artery leading to the brain – an ischaemic stroke. However, about 15 per cent are due to bleeding in or around the brain. These are called haemorrhagic strokes. This factsheet explains the different types of stroke caused by bleeding and how they are diagnosed and treated. It also lists sources of further information and support and a glossary.
Blood from the heart is pumped around the and/or pins and needles on one side of the body through a network of blood vessels body, difficulty speaking or understanding, (called arteries). This blood contains vital dizziness, or blurred vision. These can be oxygen and nutrients. If a blood vessel in or accompanied by other symptoms such around the brain bursts it can cause as a sudden, severe headache, altered bleeding, which is called a haemorrhagic consciousness, vomiting or a stiff neck. stroke. Bleeding on the surface of There are two main types: the brain •• bleeding within the brain (called an The brain itself sits inside a cushion of intracerebral haemorrhage) membranes that protects it from the skull. Between two of the layers of membranes is a •• bleeding on the surface of the brain space called the subarachnoid space that is (called a subarachnoid haemorrhage). filled with cerebrospinal fluid (CSF). If blood vessels near the surface of the brain burst Bleeding within the brain and blood leaks into the subarachnoid space, this is called a subarachnoid When an artery inside the brain bursts it haemorrhage (SAH). This accounts for five is called an intracerebral haemorrhage. per cent of all strokes. About 10 per cent of all strokes are of this type. Because the blood leaks out into the Subarachnoid haemorrhages are a very brain tissue at high pressure, the damage serious type of stroke and about 50 per cent caused can be greater than the damage of people who have one will not survive. caused by strokes due to a blockage. Symptoms Symptoms Often the only symptom is a sudden, severe Symptoms of a stroke caused by bleeding in headache. This is sometimes described as the brain can include weakness, numbness like ‘being hit over the head with a hammer’
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resulting in a blinding pain unlike anything you Aneurysm
have experienced before. Other symptoms can include altered, or loss of, consciousness, An aneurysm is a weak spot on an artery seizures, nausea and vomiting, sensitivity to that has ballooned out. Artery walls are light, neck stiffness (takes three to twelve usually thick and strong but the walls of an hours to develop), confusion and fever. aneurysm are thin and weak because they These symptoms may also be accompanied have been stretched, and therefore they by speech problems and weakness on one can burst easily. Aneurysms in the brain are side of the body. sometimes called berry aneurysms because they look like a small berry. What causes a haemorrhagic stroke? Some aneurysms are present from birth. There are also a number of risk factors High blood pressure that increase your chances of developing an aneurysm. These include smoking, The main cause is high blood pressure high blood pressure, a family history of (hypertension), which causes about two aneurysms, using cocaine, and having a thirds of all strokes due to bleeding. genetic kidney condition called autosomal dominant polycystic kidney disease. High blood pressure weakens the arteries and makes them more likely to tear. Risk High blood pressure is the main cause of an factors for high blood pressure include being aneurysm rupturing. A burst aneurysm is overweight, drinking alcohol in excess, the most common cause of an SAH, causing smoking, a lack of exercise, and stress – about 85 per cent of cases. which may cause a temporary rise in blood pressure. (See our factsheet F6, High blood Abnormal blood vessels pressure and stroke for more information.) Sometimes people are born with Cerebral amyloid angiopathy (CAA) abnormalities in their blood vessels. They are called vascular malformations, and This is a condition where a protein called are made up of a tangle of blood vessels or amyloid builds up inside the blood vessels in enlarged blood vessels. These malformations the brain. It causes damage which can cause are rare and affect less than one per cent of the vessel to tear. This condition is more the population. It is not known why some common among older people. people are born with these malformations.
CAA often leads to bleeds in specific areas There are several different types, some of of the brain near to the surface (called lobar which can lead to bleeding in the brain if the areas). Because of their position, blood can thin vessel walls break. The most common also leak into the subarachnoid space causing ones are called arteriovenous malformation an SAH as well. One study found that in (AVM), arteriovenous fistula of the dura, 63 per cent of these types of bleeds cavernous malformation and developmental in the brain, blood also leaked into the venous anomoly. subarachnoid space.
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Medication How will I be treated?
A haemorrhage can also happen if Emergency surgery
medication taken to prevent your blood from clotting is poorly controlled. These Surgery is sometimes needed to remove medicines are called anticoagulants and any blood, to relieve any pressure that has should be carefully monitored. They are built up or to repair the blood vessels. This commonly taken to reduce your risk of a is usually done with a procedure called a stroke due to a blockage if you have a type of craniotomy. This operation should be irregular heart rhythm called atrial fibrillation. carried out by a neurosurgeon.
Illegal drugs During the operation, a small piece of your
skull is cut away so the surgeon can access Some drugs, such as cocaine, irritate the the cause of the bleeding. They can then blood vessel walls making them weaker and repair any damaged blood vessels and ensure more likely to rupture. there are no blood clots that could restrict the flow of blood in your brain. If a blood clot How are strokes due to bleeding has formed, it may be removed. After the diagnosed? bleeding has stopped, the piece of skull can be replaced. Anyone with a suspected stroke should go to hospital immediately. A brain scan (a CT After this type of operation, you may be or MRI scan) should be carried out as soon placed on a ventilator (a machine to help as possible and within 24 hours to confirm you breathe). This gives your body time to the diagnosis of stroke. A brain scan should recover and can help to control swelling in take place immediately if the symptoms your brain. include a severe headache or a low level of consciousness. The brain scan will also show With any type of bleed in or around the brain, what type of stroke it is – whether it was the escaping blood can sometimes create caused by a blockage or by bleeding. a blockage that prevents the normal flow of cerebrospinal fluid. This can result in a In the case of an SAH, a lumbar puncture build up of fluid around the brain (called is usually carried out as well as a brain scan. hydrocephalus). This can cause pressure and This is a procedure to remove a sample of pain, and if left untreated, can cause damage the cerebrospinal fluid that bathes the brain to the brainstem (the base of the brain which and spinal cord. It will show if any blood has controls most of the automatic functions leaked into this fluid. that keep us alive, like breathing). Surgery to drain away the excess fluid can be carried out An angiogram is also usually carried out to using a shunt (a thin tube implanted into the locate the burst blood vessel. A fine tube brain). called a catheter is put into an artery and a dye is injected into the blood. X-rays are then used to find where the bleeding occurred.
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Surgery to seal an aneurysm If your bleed was caused by anticoagulant
medication, you will usually be given another If your stroke was caused by a burst drug to reverse the effects as soon as aneurysm, an operation may be necessary to possible. seal it and stop it bleeding again. Sometimes the operation can be done within a day or so After an SAH, blood vessels near the burst of your stroke, but if you are unconscious or aneurysm can go into spasm and prevent semi-conscious, the surgeons may wait until blood from getting to the brain. Why this you are more stable before operating. happens isn’t clear, but a lack of blood supply can lead to further brain damage. To Coiling is the most common operation that prevent this, you may be given a drug called is carried out to seal off an aneurysm. A fine nimodipine for about three weeks. After tube is inserted into an artery in the groin and this time your risk of spasm disappears carefully steered up to the aneurysm near and your doctor will usually take you off the the brain. X-rays are used to guide the tube. medication. On the tip of the tube is a platinum coil, which is released into the aneurysm. More than Pain relief such as morphine or paracetamol one coil is usually inserted. Blood then clots with codeine may be given to you to help around the coil, sealing off the aneurysm. with the severe headache associated with an SAH. Clipping involves opening the skull and making an incision in the membranes that About five per cent of people develop protect the brain to get to the aneurysm. The epilepsy after an SAH. There are a range surgeon will then put a metal clip around the of different types of medication you may base of the aneurysm so that no more blood be given to treat it. See our factsheet F24, can escape. Epilepsy after stroke for more information.
The choice of operation depends on Recovery
various factors such as your health and the aneurysm’s position. Coiling is becoming As with all types of stroke, some people the preferred treatment option as it is less recover completely, but others invasive and so causes fewer complications. need rehabilitation. Problems with communication, mobility, continence, After the operation, you will usually stay in swallowing, memory, or extreme tiredness hospital for one or two weeks. You may then are all common. Specialists such as be well enough to go home, but may need to physiotherapists, speech and language be transferred back to your local hospital for therapists, occupational therapists and further treatment or rehabilitation. continence nurses should be available to help you with your recovery. We have Medication publications covering the effects of stroke and the therapies that can help, contact us You may be given medication to lower your for copies. blood pressure, which will reduce your risk of having another stroke due to bleeding. It is quite common for people to experience
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headaches after any type of bleeding in the •• Don’t smoke.
brain. This may be due to swelling or changes in the levels of cerebrospinal fluid. The pain •• Don’t drink too much alcohol. tends to lessen over time and can usually be controlled by painkillers such as paracetamol. •• Have your blood pressure checked You should avoid taking aspirin after this type regularly. of stroke. Drinking plenty of water (two to three litres per day) and avoiding caffeine and Useful organisations alcohol can help to reduce these headaches. All organisations are UK wide unless Anyone experiencing a sudden, severe otherwise stated. headache or a persistent headache should seek medical attention urgently. Stroke Association Stroke Helpline: 0303 3033 100 Some people report strange sensations Email: info@stroke.org.uk after an SAH, like running water or a tickling Website: stroke.org.uk feeling on their brain. These are thought to Contact us for information about stroke, be harmless and usually pass in time. emotional support and details of local services and support groups. You should have your blood pressure checked regularly after a bleed in the brain, Blood Pressure Association as high blood pressure is the main cause of Information Line: 0845 241 0989 another bleed. Website: www.bpassoc.org.uk Has a wide range of information on high If you have had an SAH, you will usually be blood pressure, treatments and lifestyle. advised to have check-ups for a few years to see if there are any more aneurysms which Brain & Spine Foundation may need surgery. Helpline: 0808 808 1000 Website: www.brainandspine.org.uk If you have two or more first degree relatives Provides detailed information about (i.e. siblings or parents) who have had an neurological conditions and risk factors, SAH, you may also be advised to have a including subarachnoid haemorrhage and check-up and a type of MRI brain scan called vascular malformations of the brain. Their an MRA scan. This is to check if you have an helpline is staffed by specialist nurses. aneurysm as there is a slight hereditary risk. Brain and Spinal Injury Centre (Basic) Helping yourself Helpline: 0870 750 0000 Website: www.basiccharity.org.uk •• Take any medication you are prescribed as Provides information, support and advice directed by your doctor. by staff who have direct experience of brain injury. •• Drink plenty of fluids.
•• Eat healthily.
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Bleeding in the brain – haemorrhagic stroke
Headway – the brain injury association Craniotomy = a type of brain surgery after Tel: 0808 800 2244 a bleed in the brain to remove any blood, Website: www.headway.org.uk relieve pressure or to repair blood vessels. Has information on strokes due to bleeding and aneurysms. They also have a network of CSF = cerebrospinal fluid (fluid that bathes local branches. the brain and spine).
Scottish Head Injury Forum CT = computerised tomography (a type of
Website: www.shif.org.uk brain scan). Provides information and support to people with brain injuries including stroke in Haemorrhage = a bleed. Scotland. Hydrocephalus = build up of cerebrospinal Disclaimer: The Stroke Association fluid in or around the brain. provides details of other organisations for information only. Inclusion in this factsheet Intracerebral = within the brain. does not constitute a recommendation or endorsement. Lumbar puncture = a procedure to remove a sample of cerebrospinal fluid. Glossary of terms MRI = magnetic resonance imaging (a type Aneurysm = weak spot on an artery. of brain scan).
Angiogram = a medical procedure to locate a Subarachnoid haemorrhage (SAH) = a
burst blood vessel. type of stroke caused by bleeding on the surfaceof the brain. Anticoagulant = a type of blood-thinning medication. Subarachnoid space = space between the brain and skull. CAA = cerebral amyloid angiopathy (build up of the protein angiopathy in the blood Vascular malformations = abnormal blood vessels to the brain). vessels.
Produced by the Stroke Association’s Information Service.
Stroke Association is a Company Limited by Guarantee, registered in England and Wales (No 61274). Registered office: Stroke Association House, 240 City Road, London EC1V 2PR. Registered as a Charity in England and Wales (No 211015) and in Scotland (SC037789). Also registered in Northern Ireland (XT33805) Isle of Man (No 945)and Jersey (NPO 369).
Stroke Decoded: Understanding, Preventing, and Recovering from Brain Attacks: The NeuroHealth Collection: Understanding Diseases of the Nervous System, #6
Stroke Decoded: Understanding, Preventing, and Recovering from Brain Attacks: The NeuroHealth Collection: Understanding Diseases of the Nervous System, #6
