Haemorrhagic stroke STROKE HELPLINE FACTSHEET 25

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1 STROKE HELPLINE FACTSHEET 25 Most strokes happen because of a blockage in an artery leading to the brain, called an ischaemic stroke. However, about 20 per cent are due to bleeding in or around the brain, called a haemorrhagic stroke. This factsheet explains the different types of haemorrhagic stroke, why a haemorrhage happens and how it is diagnosed and treated. Blood from the heart is pumped along a network of blood vessels (called arteries) towards the brain. This blood contains oxygen and nutrients that the brain needs to stay alive. The arteries that travel along the neck to the brain are large and as they enter the brain they branch off into smaller and smaller arteries. These carry blood to the deepest parts of the brain. Sometimes these arteries burst sending blood rushing out of the artery, instead of into the brain cells. This is called a haemorrhagic stroke. Intracerebral haemorrhage When an artery inside the brain bursts it is called an intracerebral haemorrhage. Only 13 per cent of all strokes are intracerebral haemorrhages, however, because the blood leaks out into the brain at high pressure, the damage caused is often greater. If the blood that escapes has nowhere to go, it collects at the point of the leakage and as it grows it begins to congeal (clot) forming a mass that appears jelly-like, called a haematoma. The escaping blood causes damage to the brain cells that it contacts because of the pressure and because it blocks the oxygen and nutrients from reaching the cells. The damaged cells can die and an area of dead cells is known as an infarct. The blood usually clots within a few minutes, and over a period of months it is broken down and reduced in size as the white blood cells in the body absorb the clot. Both the size of the brain injury and the area of the brain affected determine how serious a stroke is. Risk factors The primary causes of intracerebral haemorrhage are high blood pressure (hypertension) accounting for about two thirds of people (see factsheet F6 High Blood Pressure and Stroke) and cerebral amyloid angiopathy (CAA). This is a condition where a protein called amyloid builds up inside the blood vessels to the brain and causes damage which can then cause the vessel to tear. This condition is most common amongst older people. Other common risk factors are illegal drug use, excessive alcohol intake (binge drinking), and smoking. These risk factors can all lead to vascular changes which increase the likelihood of a bleed into the brain. For example, some drugs (such as cocaine) The Stroke Association (September 2009) 1

2 irritate the blood vessel walls making them weaker and more likely to rupture. Aneurysm An aneurysm is a weakened spot on an artery that has ballooned out. The artery walls are usually thick and strong but the walls of an aneurysm are thin and weak because they have been stretched, and can burst easily. The bulging appearance differs in cause and shape and there are several types; the most common type in the brain being a berry aneurysm (so-called as it looks like a berry). Most aneurysms are present from birth. High blood pressure is the primary cause of a ruptured aneurysm. The pressure creates a bulge in an artery that eventually bursts. Sometimes people are born with other abnormal arteries. There are several different types, some of which can lead to haemorrhagic strokes if the thin vessel walls break. These are termed arteriovenous malformation (AVM), cavernous malformation and venous malformation. AVMs are rare and affect only 1 per cent of the population. The risk of a bleed from an AVM is about 1 in 50 each year. Cavernous malformations are less common. Rarer still is a bleed from a venous malformation. It is not known why some people are born with these but advances in imaging techniques are enabling us to learn more about them. A haemorrhage can also happen because of poorly controlled medication taken to prevent the blood from clotting, for example, to treat an existing medical condition. This is to reduce the risk of a blood clot forming and travelling to the brain causing an ischaemic stroke, or to the heart causing a heart attack. These medicines are called anti-coagulants and should be carefully monitored. Symptoms Symptoms can include a severe headache, altered consciousness, vomiting and a stiff neck as well as weakness, difficulty speaking and being understood, dizziness, vertigo, blurred vision, numbness and/or pins and needles. Subarachnoid haemorrhage The brain itself sits inside a cushion of membranes that protects it from the skull. Between two of the layers of membranes is a space called the subarachnoid space that is filled with cerebrospinal fluid (CSF). If blood vessels near the surface of the brain burst and leak into the subarachnoid space, this is called a subarachnoid haemorrhage (SAH). This accounts for five per cent of all strokes. A haematoma within the skull can be dangerous as the skull is unable to expand. This often results in brain tissue becoming squashed. Risk factors The most common risk factor for SAH is a burst aneurysm, causing 85 per cent of cases. CAA often results in lobar bleeds (specific areas of the brain, near to the surface). Because of their position, they can also lead to SAH. A recent study found that 63 per cent of these types of bleeds leaked into the subarachnoid space. AVMs cause about 10 per cent of cases. Smoking, high blood pressure and older age increase the risk as well. 2 The Stroke Association (September 2009)

3 Symptoms Symptoms can include a sudden, severe headache (sometimes described as like being hit over the head with a hammer this is often the only symptom), altered or loss of consciousness, coma, epileptic seizures, nausea and vomiting, sensitivity to light, neck stiffness (takes three to twelve hours to develop), confusion and fever. These symptoms may be accompanied by speech problems, difficulty keeping the leg straight and raising it, weakness, loss of sensation and delirium. Diagnosis of haemorrhagic strokes Anyone with a suspected stroke should go to hospital immediately. A brain scan a CT or MRI scan, should be carried out within 24 hours to confirm the diagnosis of stroke. This will also show what type of stroke it is either an ischaemic or haemorrhagic stroke. For SAH, as well as a brain scan, a lumbar puncture (a procedure to remove a sample of the CSF that bathes the brain and spinal cord) will show if blood has leaked into the fluid. An angiogram is usually performed to locate the burst blood vessel. A fine tube called a catheter is put into an artery through which a dye is injected. X-rays then show the position of the aneurysm. Treatment of haemorrhagic strokes Following an intracerebral haemorrhage, treatment is usually aimed at minimising secondary complications. For those taking anticoagulants, medicine is given to reverse these effects as soon as possible so that the bleed can form a clot. With any type of bleed, in or around the brain, a haematoma can sometimes create a blockage that prevents the normal flow of CSF. This can result in a build up of fluid around the brain known as hydrocephalus. This can cause pressure and pain and, if left, can cause damage to the brainstem (the base of the brain which controls most of the automatic functions that keep us alive, like breathing). Surgery to drain away the excess fluid can be carried out using a shunt (a thin tube implanted into the brain). Operations to remove a blood clot can be carried out but are complicated and risky. There is currently not enough evidence to identify who might benefit most from this type of surgery. It is usually only considered in more serious cases. Sometimes an operation to seal off an aneurysm is carried out. This is not usually considered for an intracerebral aneurysm as a burst blood vessel within the brain can be difficult to reach. For SAH, an operation may be necessary and requires transfer to a specialised neurosurgical unit. Sometimes the operation can be done within a day or so of the SAH, but surgeons usually wait until unconscious or semi-conscious patients are more stable before operating. Waiting too long may increase the risk of another haemorrhage, but operating on a weakened patient may be fatal. Treatment has two primary aims to seal off the burst aneurysm and to prevent spasm in nearby blood vessels, which could starve the brain of oxygen. Open surgery involves opening the skull and making an incision in the membranes The Stroke Association (September 2009) 3

4 that protect the brain to get to the burst blood vessel. The surgeon will then put a metal clip around the neck of the aneurysm so that no more blood can escape. Another option is endovascular coiling (sometimes called coil embolisation or just coiling). This can be carried out without opening up the skull. Instead, the surgeon seals the aneurysm from inside. Like angiography, a fine tube is inserted into an artery in the groin and carefully steered up to the aneurysm near the brain. X-rays are used to guide the tube. On the tip of the tube is the platinum coil, which is released into the aneurysm. Multiple coils are usually inserted. The choice of operation depends on various factors, including the patients health and the position of the aneurysm. Endovascular coiling is becoming the preferred treatment option due to its higher success rate of 77 per cent of people making a good or full recovery, compared to 70 per cent following open surgery. After sealing the aneurysm, the patient will usually stay in hospital for one or two weeks. Some are then well enough to go home, but others are transferred back to their local hospital. Drug therapy After an SAH, blood vessels near the burst aneurysm can go into spasm and prevent blood from getting to the brain. Why this happens isnt clear, but a lack of blood can lead to brain damage. To prevent this, people who have had an SAH are given a drug called nimodipine for about three weeks. After this time the risk of spasm disappears and your doctor will usually take you off the medication. It is quite common for people to experience headaches after any type of brain haemorrhage. This may be due to swelling or changes in the levels of CSF. The pain tends to lessen over time and can usually be controlled by painkillers such as paracetamol (aspirin should usually be avoided after this type of stroke). Drinking plenty of water (2 3 litres per day) and avoiding caffeine and alcohol can help to reduce these headaches. Anyone experiencing a sudden, severe headache or a persistent headache should seek medical attention urgently to find out what is causing it. When you get home As with all types of stroke, (ischaemic and haemorrhagic), some people recover completely, but others are left with some brain damage and may need rehabilitation. Difficulty with communication, mobility, continence, swallowing, memory or extreme tiredness are all common effects that may be experienced. Specialists such as speech and language therapists, dieticians, physiotherapists and continence nurses should be available to help with recovery. About five per cent of people develop epilepsy after SAH. For this reason anyone who has had a haemorrhage must notify the DVLA. You will not be able to drive for a period of time, usually up to a year. If you do have seizures, you will not be allowed to drive again until these are well-controlled. People who recover well can go back to work and exercise normally. Most women who have had surgery to treat an aneurysm The Stroke Association (September 2009) 4

5 can safely become pregnant, although they may be advised to avoid becoming pregnant for the first six months. Only when the haemorrhage is due to a rare blood vessel abnormality is pregnancy dangerous. Some people report strange sensations after SAH, like running water or a tickling feeling on their brain. These are thought to be harmless and usually pass in time. What is the outlook? The risk of death following an intracerebral haemorrhage is around 35 to 40 per cent of people. It is greatest in the first month after the stroke, and more likely to occur in someone who has suffered a deep haemorrhage. This risk increases with the volume of the bleed. A follow-up appointment to have blood pressure monitored should be recommended as high blood pressure is the main cause of a re-bleed. If the cause of the bleed is unknown, a follow-up will be offered for three months time. After this time the blood clot will have broken down and disappeared and it should be easier to see what has caused the bleed. About half of those who have an SAH die within a few weeks. If they survive the initial bleed and are transferred quickly to a specialist centre, the outlook is usually good. The risks of a berry aneurysm causing a bleed are very rare so it is not usual for screening to be carried out. People who have had an SAH are usually advised to have check-ups for a few years to see if there are any more aneurysms suitable for surgery. Those who have two or more first degree relatives (ie siblings or parents) who have had an SAH may also be advised to have check-ups every five years. Anyone who has had an SAH or those with SAH in the family should not smoke, should keep alcohol intake to a minimum and should have their blood pressure checked regularly. Useful organisations All organisations are UK wide unless otherwise stated. Blood Pressure Association 60 Cranmer Terrace, London SW17 0QS Information Line: Website: Has a wide range of information on high blood pressure, treatments and lifestyle. Brain & Spine Foundation 3.36 Canterbury Court, Kennington Park, 13 Brixton Road, London SW9 6DE Helpline: Website: Carries out research and develops education to help prevent disorders of the brain and spine. Has information about subarachnoid haemorrhage and vascular malformations of the brain. Brain and Spinal Injury Centre (Basic) 554 Eccles New Road, Salford M5 5AP National Helpline: Website: Provides information, support and advice by staff who have direct experience of brain injury. Chest, Heart and Stroke Scotland (CHSS) Head Office, 65 North Castle Street, Edinburgh EH2 3LT Advice Line: Website: The Stroke Association (September 2009) 5

6 Provides information and support to people affected by chest, heart or stroke illness. Different Strokes 9 Canon Harnett Court, Wolverton Mill Milton Keynes MK12 5NF Tel: or visit: Run by younger stroke survivors and provides information and support to younger people who have experienced a stroke. Headway the brain injury association 190 Bagnall Road, Old Basford, Nottingham NG6 8SF, tel: , website: Has information on stroke, brain haemorrhage and aneurysm. Scottish Head Injury Forum c/o Fife Traumatic Brain Injury Service Social Work Service 70 Stenhouse Street Cowdenbeath KY49DD Tel: Website: Provides information and support to people with an acquired brain injury including stroke. The Vascular Society The Royal College of Surgeons of England 3543 Lincolns Inn Fields, London WC2A 3PE, tel: Website: Disclaimer: The Stroke Association provides the details of other organisations for information only. Inclusion in this factsheet does not constitute a recommendation or endorsement. Glossary of terms Aneurysm = Weak spot on an artery AVM = Arteriovenous Malformations (abnormal artery formations) CAA = Cerebral Amyloid Angiopathy (build up of protein angiopathy in the blood vessels to the brain) CSF = cerebrospinal fluid (fluid that bathes the brain and spine) CT = Computerised Tomography (a type of brain scan) Haematoma = Collection of blood, usually clotted within tissue or an organ Haemorrhage = a bleed Hydrocephalus = Build up of CFS in or around the brain Intracerebral = within the brain MRI = Magnetic Resonance Imaging (a type of brain scan) Subarachnoid = space between the brain and skull SAH = subarachnoid haemorrhage For further information, phone the Stroke Helpline on , or visit our website If you are unhappy about any aspect of The Stroke Association, please make your views known to us immediately. We will happily discuss any issues and how they can best be resolved. Produced by The Stroke Associations Information Service. For sources used, visit our_publications Factsheet 25, version 02, published September 2009, updated March 2010 (next revision due Sepember 2011). F25 Haemorrhagic Stroke The Stroke Association The Stroke Association is registered as a Charity in England and Wales (No ) and in Scotland (SC037789). Also registered in Isle of Man (No 945) Jersey (NPO 369) and in Northern Ireland. 6 The Stroke Association (September 2009)

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