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Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue.

See also:

• Cerebral aneurysm
• Deep intracerebral hemorrhage
• Hypertensive intracerebral hemorrhage
• Intracerebral hemorrhage
• Lobar intracerebral hemorrhage
• Subarachnoid hemorrhage

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:

• Intracerebral hemorrhage: Bleeding in the brain
• Subarachnoid hemorrhage: Bleeding in the area between the brain and the thin tissues that cover the brain

Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls until they break.

Other causes of hemorrhagic stroke include:

• Aneurysms, which create a weak spot in an artery wall, which can eventually burst
• Abnormal connections between arteries and veins, such as an arteriovenous malformation (AVM)
• Cancer, particularly cancer that spreads to the brain from distant organs such as the breast, skin, and thyroid
• Cerebral amyloid angiopathy, a build up of amyloid protein within the artery walls in the brain, which makes bleeding more likely
• Conditions or medications (such as aspirin or Warfarin) that can make you bleed excessively
• Illicit drugs, such as cocaine

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:

• Change in alertness (level of consciousness)
  • Apathetic
  • Coma
  • Lethargy
  • Sleepiness
  • Stupor
  • Unconsciousness
  • Withdrawn
• Difficulty speaking or understanding others
• Difficulty swallowing
• Difficulty writing or reading
• Headache
  • Occurs when lying flat
  • Wakes you up from sleep
  • Gets worse when you change positions or when you bend, strain, or cough
  • Starts suddenly
• Loss of coordination
• Loss of balance
• Movement changes, usually on only one side of the body
  • Difficulty moving any body part
  • Loss of fine motor skills
• Nausea or vomiting
• Seizure
• Sensation changes, usually on only one side of the body
  • Decreased sensation
  • Numbness or tingling
• Weakness of any body part
• Vision changes
  • Decreased vision
  • Loss of all or part of vision

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.

Conventional angiography may be done in some cases to identify aneurysms or an arteriovenous malformation, although CT and MRI are more often used.

Other tests may include:

• Complete blood count (CBC)
• Blood clotting studies --prothrombin time (PT) and partial thromboplastin time (PTT)
• CSF (cerebrospinal fluid) exam

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.

• Decreased social interaction
• Decreased ability to function or care for self
• Decreased life span
• Difficulty communicating
• Joint contractures
• Muscle spasticity
• Permanent loss of cognitive or other brain functions (dementia)
• Permanent loss of movement or sensation of one or more parts of the body
• Pressure sores due to lack of movement
• Urinary and respiratory tract infections

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:

• Difficulty breathing
• Loss of ability to move or swallow
• Loss of consciousness
• Seizures
• Sudden loss of sensations
• Sudden change in mental state

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.