Brain Hemorrhage (Brain Bleed)

Types of brain hemorrhage

The skull contains the brain wrapped in three layers (meninges). Bleeding is named by where it occurs:

Intracerebral and subarachnoid hemorrhages are types of stroke. They make up about 10 to 15% of all strokes but cause a larger share of stroke deaths.

Symptoms

Symptoms depend on the location and size of the bleed, and usually come on suddenly:

• Sudden severe headache, often described as the worst ever
• Weakness, numbness or paralysis of the face, arm or leg, usually on one side
• Trouble speaking or understanding speech
• Vision changes, double vision
• Loss of balance or coordination
• Nausea and vomiting
• Confusion, drowsiness or loss of consciousness
• Seizures
• Stiff neck and sensitivity to light, especially with subarachnoid bleeding

Chronic subdural hematomas in older adults may cause only gradual confusion, personality change, headache or falls.

Causes and risk factors

• High blood pressure: the most common cause of intracerebral hemorrhage. Years of hypertension weaken small arteries deep in the brain.
• Head injury: falls, road traffic accidents and assaults. See traumatic brain injury.
• Ruptured cerebral aneurysm: a weak, ballooned artery wall, the main cause of non-traumatic subarachnoid hemorrhage.
• Arteriovenous malformation: a tangle of abnormal vessels, a common cause in younger people.
• Cerebral amyloid angiopathy: protein deposits weaken vessels near the brain surface in older adults, causing recurrent lobar bleeds.
• Blood thinners: warfarin, direct oral anticoagulants and, to a lesser degree, antiplatelet medicines.
• Bleeding disorders and liver disease.
• Heavy alcohol use, smoking, cocaine and amphetamines.
• Brain tumors that bleed.

Diagnosis

1. Emergency CT scan of the head: quickly shows fresh blood and its size and location.
2. CT angiography: looks for an aneurysm, AVM or active bleeding.
3. MRI: identifies underlying causes such as amyloid angiopathy, tumors or small vascular malformations.
4. Lumbar puncture: if subarachnoid hemorrhage is suspected but the CT is normal.
5. Blood tests: clotting tests, blood count, kidney function and glucose.
6. Catheter angiography: the most detailed view of blood vessels, often combined with treatment.

Treatment

Emergency treatment

• Protecting the airway and breathing, in intensive care if needed.
• Lowering blood pressure carefully to reduce further bleeding.
• Reversing blood thinners urgently with vitamin K and prothrombin complex concentrate, idarucizumab or andexanet alfa, depending on the drug.
• Controlling seizures, fever and blood sugar.
• Managing pressure inside the skull, for example with a drain for fluid buildup (hydrocephalus).

Surgery and procedures

• Evacuation of the clot: for epidural and many acute subdural hematomas, and selected intracerebral hemorrhages, especially in the cerebellum.
• Burr hole drainage: for chronic subdural hematomas.
• Aneurysm treatment: endovascular coiling or surgical clipping to prevent rebleeding.
• AVM treatment: surgery, embolization or focused radiation.
• Minimally invasive clot removal is increasingly used in selected patients.

Rehabilitation

Rehabilitation starts in hospital as soon as it is safe and continues for months:

• Physical therapy for weakness, balance and walking
• Occupational therapy for daily tasks such as dressing and eating
• Speech and language therapy for speech and swallowing
• Neuropsychology for memory, attention and mood

Recovery after a brain hemorrhage

Recovery varies widely. Most improvement happens in the first 3 to 6 months, but gains can continue for a year or more.

Recovery from hemiplegia in older adults

Hemiplegia, weakness or paralysis on one side of the body, is common after intracerebral hemorrhage. Left-sided hemiplegia comes from bleeding in the right side of the brain and often comes with neglect of the left side (not noticing things on that side) and problems with spatial awareness. Older adults can still recover meaningful function, although recovery may be slower. Factors that help include:

• early, frequent and task-specific therapy
• prevention of complications such as pneumonia, blood clots, pressure sores, shoulder pain and falls
• treating depression, which affects about a third of stroke survivors
• family involvement and home adaptations
• control of blood pressure to prevent another bleed

Some people need long-term help with mobility or daily activities, and a care plan, equipment and home modifications make this safer.

Complications

• Rebleeding, particularly from untreated aneurysms
• Brain swelling and raised pressure
• Hydrocephalus
• Seizures and epilepsy
• Vasospasm (narrowing of arteries) after subarachnoid hemorrhage, causing delayed stroke
• Pneumonia, blood clots in the legs, and infections
• Long-term disability, memory problems and mood changes

Outlook

Brain hemorrhage is serious, and about 40% of people with intracerebral hemorrhage die within a month. The outlook depends on the size and location of the bleed, age, level of consciousness on arrival, and speed of treatment. Survivors often make substantial gains with rehabilitation.

Prevention

• Control blood pressure: the single most effective step.
• Stop smoking, limit alcohol and avoid stimulant drugs.
• Take blood thinners exactly as prescribed, with regular monitoring if on warfarin.
• Prevent falls in older adults, and wear helmets and seat belts.
• Follow screening advice if two or more close relatives have had brain aneurysms.

Frequently asked questions

What are the first signs of a brain hemorrhage?

The first signs are usually sudden: a severe headache, weakness or numbness on one side, trouble speaking, vision changes, vomiting, confusion or drowsiness. Seizures can occur. Call 911 immediately, because rapid treatment improves the outcome.

What causes a brain bleed?

The most common causes are high blood pressure, head injuries, ruptured aneurysms, arteriovenous malformations, fragile vessels from amyloid angiopathy in older adults, and blood-thinning medicines. Heavy alcohol use and stimulant drugs increase the risk.

Can you recover from a brain hemorrhage?

Many people survive and recover significant function, especially with prompt treatment and rehabilitation. Most improvement occurs in the first 3 to 6 months. Some people have lasting weakness, speech or memory problems and need ongoing support.

Can an elderly person recover from left-sided paralysis after a brain bleed?

Yes, partial or substantial recovery is possible at any age, although it may be slower and less complete in older adults. Early, intensive rehabilitation, preventing complications and treating depression all improve the chances of regaining walking and independence.

Is a brain hemorrhage the same as a stroke?

Some are. Intracerebral and subarachnoid hemorrhages are hemorrhagic strokes. Bleeds caused by head injuries, such as subdural and epidural hematomas, are usually classed as traumatic brain injuries rather than strokes.