Cerebrovascular Accident - Hemorrhagic Stroke
Overview, Causes, & Risk Factors
A stroke is the death of brain tissue that occurs when the brain does not get
enough blood and oxygen. Hemorrhagic stroke is a serious condition that occurs
when blood seeps into the brain tissue from a damaged blood vessel.
What is going on in the body?
A hemorrhagic stroke occurs when blood vessels in the brain burst
and release blood into the area around the brain cells. The blood then damages
the brain cells. The products released when cells die cause swelling in the
brain. Since the skull doesn't allow much room for expansion, this swelling can
damage the brain tissue even further.
What are the causes and risks of the condition?
A hemorrhagic stroke may be caused by:
high blood pressure
abnormal bleeding from blood-thinning medications, such as warfarin or
hemophilia A or
hemophilia B, which are blood
prevent normal blood clotting
low numbers of platelets, a type of blood cell involved in blood
clotting. Low platelet counts are seen in a number of diseases and conditions,
including acute infections and a severe allergic reaction known as anaphylactic shock.
rupture of a cerebral
weakened blood vessel wall within the brain
sickle cell disease, an inherited condition that results in
abnormal red blood cells
a group of abnormal blood vessels within the brain known as an
arteriovenous malformation or AVM
eclampsia, a complication of
pregnancy that causes high blood pressure in the mother
The person's risk of hemorrhagic stroke is increased if other risk factors for
stroke are also present.
The American Heart Association has recently issued guidelines for stroke
prevention. The guidelines discuss risk factors for stroke in 3 categories:
nonmodifiable, well-documented modifiable, and less well-documented or
The nonmodifiable factors are ones that cannot be changed by the individual
increasing age. A person's risk of stroke doubles each year after age
race. Strokes occur approximately twice as often in blacks and Hispanics as
they do in whites.
gender. Men have a 50% higher chance of stroke than women do.
family history of stroke or
ischemic attack (TIA). A TIA is a short, reversible form of stroke
may serve as an early warning sign of stroke.
Well-documented modifiable risk factors are those that can be changed by the
individual in conjunction with his or her healthcare provider. These factors
are linked to stroke by strong research findings, and there is documented proof
that changing the risk factor lowers a person's risk of stroke. These factors
high blood pressure
narrowing of one of the arteries in the neck
sickle cell anemia,
disorder that forms abnormal red blood cells
high cholesterol levels
blood, including total
LDL or "bad
cholesterol." Low levels
of HDL or "good
cholesterol" are also
cause for concern.
Less well-documented or potentially modifiable risk factors for stroke are
those that have less proof of either a link to stroke or the impact of
modifying the risk factor. These factors include:
a sedentary lifestyle with inadequate physical activity
high blood levels of homocysteine, a blood component sometimes associated
with a higher risk of stroke
blood disorders, such as blood that clots easily or deficiencies of various
The AHA currently states that the risk of stroke associated with HRT appears
low but needs further study.
birth control pills, or oral
inflammatory processes, such as a chronic infection with chlamydia
Several recent studies have identified factors that seem to increase or
decrease the risk of stroke in particular groups of people. These studies,
which warrant further investigation, include these findings:
People who were treated for high
pressure with thiazide diuretics, such as hydrochlorothiazide, had
significantly lower stroke risk than people on ACE inhibitors or calcium
Women ages 15 to 44 who had 2 drinks of wine a day had a 40% to 60% lower
risk of stroke than women who did not drink
Phenylpropanolamine, a compound contained in appetite suppressants and cold
remedies, significantly increased the risk of hemorrhagic stroke in women 18 to 49
years of age. The Food and Drug Administration (FDA) has since asked
manufacturers to remove phenylpropanolamine from their product lines.
In one study, people who were treated in emergency departments for
transient ischemic attacks (TIA) had a 25% chance of having a stroke or other
serious health event within the next 90 days.
Symptoms & Signs
What are the signs and symptoms of the condition?
Strokes can cause many different signs and symptoms, depending on the area of
the brain that is damaged. Some people have multiple areas of damage. Most
strokes begin suddenly, develop rapidly, and cause brain damage within minutes.
Signs or symptoms may include:
problems with movement, such as weakness, clumsiness, or paralysis.
These are often on only one side of the body. In some cases, people may only
have weakness or clumsiness in their hand. In other cases, one entire half of
the body becomes paralyzed.
numbness or a lack of feeling, which is also often on only one side
of the body
slurred speech or difficulty finding the correct word
difficulty doing math or writing
difficulty understanding speech or writing
inability to recognize family members or common objects
dementia, a condition that affects memory, understanding, and the
ability to carry out the normal activities of daily life
blurred vision or total vision loss
balance problems, known as ataxia
the inability to breathe on one's own. This may require a person to be put
on an artificial breathing machine, or
Diagnosis & Tests
How is the condition diagnosed?
Cranial MRIs and
scans may be ordered to show the type, size, and location of the
Blood tests may be done if the person is on blood-thinning medication. Blood flow tests using ultrasound or angiography may be
Prevention & Expectations
What can be done to prevent the condition?
Some hemorrhagic strokes can be prevented through careful control
of the underlying disease or disorder. Careful management of sickle cell anemia or hemophilia A or B
, for example, can reduce hemorrhage strokes. For individuals with diagnosed
monitoring and treatment should be followed.
Hemorrhagic stroke from head injuries can be minimized by following sports
safety guidelines for
children, adolescents, and adults.
The American Heart Association guidelines for stroke prevention address both
modifiable and less well-documented or potentially modifiable risk factors.
Measures to reduce the modifiable risk of
high blood pressure, a leading cause of stroke, include:
measurement of blood
adults at least every 2 years to screen for
high blood pressure
moderation in alcohol
moderate sodium intake
for those who smoke, quitting
medications to treat high blood pressure if the person's blood pressure is
over 140/90 after 3 months of these lifestyle modifications, or if the initial
blood pressure is over 180/100
Other measures to reduce an individual's modifiable risk factors for stroke may
patches, counseling, and formal smoking programs
control of blood sugar levels in a person with diabetes through medication, diet, and exercise
the use of ramipril in people with diabetes. A recent study showed that people with diabetes have a 33% lower risk of stroke if they take ramipril.
careful evaluation of asymptomatic carotid stenosis to determine the need for surgery. Coronary artery surgery, such as an endarterectomy,
indicated. An endarterectomy opens the narrow portion of the artery and
increases the blood flow to the brain. People with carotid stenosis should
also work closely with their healthcare providers to control other risk factors
semiannual screening of children with
sickle cell anemia, using ultrasound to determine the child's risk
treatment of atrial
with blood thinners such as aspirin or warfarin, depending on the person's age
and other risk factors
monitoring of high levels of total cholesterol or LDL, as well as low
levels of HDL. Depending on the blood levels and the person's other risk
factors, medications to lower cholesterol may be given.
Measures to reduce less well-documented or potentially modifiable risks for
stroke may include:
weight reduction in overweight persons
30 or more minutes of moderate exercise a day for most individuals.
People with heart disease
disabilities should be in a medically supervised exercise program.
a healthy diet for heart
containing at least 5 fruits and vegetables a day
for those who drink
drinking in moderation. The AHA defines moderate drinking as no more than 2
drinks a day for men and 1 drink a day for women.
seeking treatment for drug
monitoring of blood levels of homocysteine. For most individuals, a
well-balanced diet following the food guide pyramid will provide enough folic
acid and B vitamins to maintain a healthy homocysteine level. For people with
elevated homocysteine levels, supplements containing folic acid and B vitamins
may be recommended.
avoiding the use of oral contraceptives in women with other stroke risk
Some people have early warning signs that they are at risk for strokes. The
most common warning sign is what is known as a transient ischemic
attack, or TIA. This is a type of reversible stroke that often goes
away after a few minutes. These people can often get treatment that will
prevent a stroke in the future. For instance, people may be advised to take
aspirin or have carotid artery surgery to correct a blockage in a
What are the long-term effects of the condition?
Strokes can cause death or permanent disability. Though many people recover
some function in the first several months after a stroke, others show no
improvement. Some people have several small strokes over time and slowly get
worse with each one.
What are the risks to others?
Strokes are not contagious and pose no risk to others.
Treatment & Monitoring
What are the treatments for the condition?
If someone has the early warning signs of stroke, the emergency medical system should be contacted
These signs include a sudden onset of:
weakness or numbness
of the face,
arm, or leg, especially on one side of the body
trouble walking or loss of balance, known as ataxia
trouble speaking or understanding speech
Supportive therapy may also be needed with some strokes. This may include an artificial breathing machine, or
ventilator, and an artificial
feeding tube if the person cannot swallow.
Rehabilitation services can help to improve a person's function after a stroke.
Physical therapy and other therapy, such as speech
therapy or occupational therapy, may be used to maximize
What are the side effects of the treatments?
Side effects depend on the treatments used. For example, a ventilator may sometimes cause damage to the
lungs or an
What happens after treatment for the condition?
After the person is stable, treatment of the risk factors for stroke, as well
as the cause of the stroke, is important to prevent further strokes. For
instance, stopping smoking and controlling high blood pressure,
diabetes, and high
are advised for most people.
Many people need assistance of one form or another after a stroke. This may
range from using a walking cane to needing 24-hour-a-day skilled nursing
care. Ongoing therapy to improve function is usually advised for at least 6
months if the person is able.
How is the condition monitored?
People having a stroke are often admitted to the hospital for close monitoring.
Once the person is stable, he or she can often be sent home or to a skilled
nursing facility or rehabilitation center for further therapy. Any new or
worsening symptoms should be reported to the healthcare provider.
Author:Gerald C. McIntosh, MD
Editor:Ballenberg, Sally, BS
Reviewer:Eileen McLaughlin, RN, BSN