A hemorrhagic stroke occurs when a weakened blood vessel ruptures and bleeds either inside or on the surface of the brain. Some of these hemorrhages happen because of a ruptured aneurysm (called a subarachnoid hemorrhage). Others are caused by arteriovenous malformations (AVM), which are abnormal tangles of blood vessels that disrupt normal blood flow and oxygen circulation. The most common cause, however, is high blood pressure leading to a rupture of small arteries deep inside the brain.

A hemorrhagic stroke is classified by its location: an intracerebral hemorrhage occurs within the brain; a subarachnoid hemorrhage occurs in the space between the inner and outer layers of tissue that envelop the brain.

Hemorrhagic strokes, which account for 10 – 15% of all strokes, are less common than ischemic strokes—the kind most people associate with stroke. Ischemic strokes arise when a traveling blood clot or atherosclerosis in the arteries limits the flow of blood to the brain.

Hemorrhagic strokes are more common among men than women. Age (being 65 or older) is a risk factor for hemorrhagic stroke, with risk increasing as the years go by.

Hemorrhagic stroke is a neurological emergency that occurs when a blood vessel inside or on the surface of the brain ruptures. The hemorrhage occurs suddenly and may result in death, especially when a large aneurysm is the cause. Those who survive a hemorrhagic stroke are much more likely to experience long-term disability.

There are three common causes of a ruptured blood vessel that result in a hemorrhagic stroke:

• Hypertension (high blood pressure), which can cause small arteries deep in the brain to rupture.
• Cerebral aneurysm, when a weak spot develops on the wall of an artery within the brain, often at a location where the artery branches out. As blood passes by this weak spot, pressure increases, forming an outpouching (or aneurysm). As the aneurysm grows, the walls become thinner and weaker, eventually leading to rupture.
• Arteriovenous malformation (AVM), when an abnormal bundle of arteries and veins forms in the brain, creating a higher risk of hemorrhage. AVMs are rare, affecting only about 1% of people.

Most hemorrhagic strokes are caused by hypertension, when an artery ruptures in the brain. Smoking and hypertension are risk factors for developing aneurysms. AVMs tend to develop sporadically. A common cause of hemorrhage in older patients is cerebral amyloid angiopathy (CAA), which can lead to accumulation of smaller asymptomatic “microbleeds” in the brain, and a higher risk of a large hemorrhage that can cause stroke-like symptoms.

Other possible causes include:

• Blood thinners
• Smoking or heavy alcohol use
• Cocaine or amphetamine use
• Cavernomas (cluster of isolated blood vessels)
• Head trauma
• Bleeding disorders
• Brain tumors
• Endocarditis (infection of the heart valves)

People who have a hemorrhagic stroke may experience:

• A sudden, intense headache
• Double or blurry vision
• Confusion
• Lethargy
• Memory problems
• Trouble speaking or understanding others
• Weakness or paralysis in the face, one arm, leg, or side of the body
• Loss of sensation on one side of the body
• Nausea or vomiting
• Loss of consciousness
• Seizures
• A stiff neck

If stroke of any kind is suspected, call 911 immediately. To diagnose the type of stroke a person has had, doctors will ask about medical history, perform a physical exam, and get diagnostic tests. Doctors work quickly to definitively diagnose the condition, so that they may begin treatment quickly.

Hemorrhagic stroke can lead to sleepiness, confusion, or unconsciousness, so relatives may need to provide details about a patient’s medical history. Doctors may ask if the patient has high blood pressure or a bleeding disorder and if they take blood thinners. They may also ask if the patient smokes, drinks alcohol, or uses illegal substances.

During a physical exam, doctors look for signs that may suggest hemorrhagic stroke, including abnormal mental status, difficulty with communication, abnormal eye movements, weakness on one side of the body, facial droop, or limited movement of the neck.

The following tests are often used to diagnose a hemorrhagic stroke:

• A CT scan (without contrast) is the fastest, most widely available, and reliable method to rule out a hemorrhagic stroke. All patients should be able to get a CT scan without any barriers.
• An MRI can show the location of a hemorrhage in or around the brain and any prior strokes. An MRI can take longer to arrange and may not be an option for some patients who have artificial valves, pacemakers, or other metal in their bodies.
• A series of blood tests, including a complete blood count (CBC), a blood glucose test, and coagulation studies, to rule out other conditions
• CT angiography, which looks at blood vessels to identify an aneurysm or AVM
• A spinal tap, which can test for subarachnoid hemorrhage if a CT scan is not helpful and suspicion of a hemorrhagic stroke is still high

Hemorrhagic stroke is a serious, life-threatening medical emergency. A patient who experiences one—or their loved ones—should call 911 immediately. They will be admitted to the intensive care unit of a hospital as soon as possible.

Treatments include:

• Hemostatic therapy. In many patients, a hematoma continues to expand in size over the first 24 hours, which may lead to further brain injury. Doctors work to reduce the size of the hematoma, which may help increase survival. Some hematomas are removed surgically, but many do not require surgery. If a patient has high blood pressure, medication such as beta-blockers, calcium channel blockers, or ACE inhibitors may be used to lower blood pressure levels.
• Surgery to repair an aneurysm. Surgeons may place a stent, coil, or clip at the site to stop the bleeding and reinforce the weakened blood vessel wall.
• Surgery to remove an arteriovenous malformation. This procedure may be recommended if the malformation is easily accessible and not located deep within brain tissue.
• Stereotactic radiosurgery. When an arteriovenous malformation is inaccessible by surgery, this procedure may be used to prevent the malformation from bleeding again. Doctors aim high-energy beams at the weakened spot, creating scar tissue at the site that prevents future bleeding.
• Reducing pressure on the brain. The head of the patient’s bed may be elevated at a 30-degree angle to help relieve pressure. Other medical treatments to control brain swelling may also be used.
• Pain medication. If a patient’s headache is intense, medication may be prescribed to alleviate the pain.
• Anti-seizure medication. Nearly one-third of people who survive hemorrhagic stroke experience seizures during the first few weeks following the initial episode. Anti-seizure medications are used in that situation.

To reduce the risk of recurrent hemorrhagic stroke, doctors may recommend:

• Controlling blood pressure
• Quitting smoking
• Consuming less alcohol
• Avoiding cocaine and amphetamine use
• Stopping blood thinners (anticoagulant drugs)

Hemorrhagic strokes have worse outcomes than ischemic strokes. About half of people who experience hemorrhagic stroke die within weeks of the event. When the cause of the stroke is an aneurysm, about one-third of people die before they reach the hospital for treatment.

Most people with an intracerebral hemorrhage will have some degree of lasting impairment and do not return to their pre-stroke level of function. The possibility of brain function recovery is higher for those with a subarachnoid hemorrhage since the bleeding occurs on the surface of the brain and not inside of it.

“The Comprehensive Stroke Center at Yale provides expertise in the management of both ischemic and hemorrhagic strokes,” says Yale Medicine stroke specialist Hardik P. Amin, MD. “We have a stroke team ready 24-7 that can perform state-of-the-art imaging in the emergency room and provide rapid medical and surgical treatments to maximize the chance of recovery.”

Our team of highly experienced stroke neurologists and neurosurgeons, dedicated trainees, specialized nurse practitioners, and nurse navigators provide comprehensive care for stroke patients from the moment they arrive at the emergency room, through their hospital stay, and when they are seen in our follow up clinics, Dr. Amin adds.

“By pairing a thoughtful, individualized approach with state-of-the-art imaging and diagnostic testing, we work to understand the cause of each patient’s stroke and how to lower the risk of future events,” Dr. Amin says. “Our physical, occupational, and speech therapists provide detailed patient evaluations to set patients on a path to reaching their full rehabilitation potential. We also participate in national clinical trials to help further our understanding of stroke causes and treatments.”