A stroke from brain bleed is a special kind of stroke. A regular stroke (also called ischemic stroke) is caused by a blockage of blood flow to the brain, while a stroke from brain bleed is caused by a bleeding artery inside the brain. Before treating any stroke, the most important task is to make sure that it is not a stroke from brain bleed.
In the last 15 years, I have personally treated many patients hospitalized with regular strokes as well as strokes from brain bleed. In this article, I will describe what a stroke with brain bleed is and distinguish it from other types of bleeding in the brain. I will also compare strokes with brain bleed to regular strokes, and tell you the risk factors for a stroke with brain bleed. Finally, I will tell you what to expect when hospitalized with a stroke from brain bleed.
Is brain bleed always a stroke?
No, certainly not.
There are many different types of brain bleed. Strokes from brain bleed are a special kind of brain bleed. Medically, it is known as a hemorrhagic stroke. Brain bleed caused by a car accident, bleeding around the brain, or bleeding under the skull are other types of brain bleed that are not an actual hemorrhagic stroke.
Bleeding after a regular stroke is also different than a stroke from brain bleed. You can read this article (link) if you would like to understand how brain bleed can happen after a stroke.
Strokes from brain bleed (hemorrhagic stroke) vs regular strokes (ischemic stroke)
Strokes from brain bleed and regular strokes have many common symptoms. However, there are a few symptoms that are more specific to a stroke with brain bleed. The most important distinguishing symptom is the presence or absence of a headache. A regular ischemic stroke is almost always painless. I have explained this in the article “stroke vs heart attack.” It is very unusual for someone with a regular stroke to have a bad headache. When you have a bad headache with stroke-like symptoms, you are more likely to have a stroke from brain bleed.
Here is a table comparing the symptoms of hemorrhagic strokes with ischemic strokes:
| Signs or symptoms | Hemorrhagic Stroke | Ischemic Stroke |
|---|---|---|
| Headaches | Mostly present | Mostly absent |
| Seizures | More likely | Less likely |
| Lethargy | More likely | Less likely |
| Nausea and vomiting | More likely | Less likely |
| Distorted face with blunting of the smile lines on one side | Maybe present | Maybe present |
| Weakness of the lips and cheek muscles on one side | Maybe present | Maybe present |
| Problems with vision | Maybe present | Maybe present |
| Problems with finding the right words to say | Maybe present | Maybe present |
| Weakness of arms or legs or both on one side | Maybe present | Maybe present |
| Problems with balance | Maybe present | Maybe present |
| Problems with hand-eye coordination | Maybe present | Maybe present |
Risk factors for strokes from brain bleed
Here are the risk factors for a hemorrhagic stroke:
- High blood pressure: Uncontrolled high blood pressure is the most important risk factor for a stroke from brain bleed. Your risk of brain bleed goes higher as your blood pressure goes up.
- Smoking: Smoking greatly increases your risk of having a stroke from brain bleed. The risk seems to go down slowly after you quit smoking. Taking care of high blood pressure and quitting smoking are the two most important things you can do to prevent a hemorrhagic stroke.
- Alcohol abuse: Heavy drinking has been identified as an important risk factor for a stroke from brain bleed.
- Blood thinners: People who are on blood thinners for a history of blood clots or other conditions are at an increased risk of having a stroke from brain bleed. In most cases when blood thinners are required, the risk of not taking blood thinners is higher than the risk of getting brain bleed. It is important to understand the risks and benefits of taking blood thinners for any medical condition.
- The use of aspirin and similar medications for the prevention of regular strokes or heart attacks: Aspirin and similar medications prevent platelets from sticking to the arteries and help prevent the formation of plaques that may lead to heart attacks or strokes (link here). Platelets are small particles in the blood that stick together to help make blood clots. When platelets are ineffective, you can have an increased risk of bleeding, including bleeding in the brain.
- Illicit drug use: Certain drugs such as cocaine and meth can directly lead to a stroke from brain bleed.
- Unmodifiable risk factors: Men are at a higher risk of strokes from brain bleed than women. Asian Americans are at higher risk for hemorrhagic strokes than any other ethnic groups in the United States. Your risk of a hemorrhagic stroke goes up as you get older.
What to expect when hospitalized for a stroke from brain bleed
The treatment plan starts as soon as you call 911 after suspecting a stroke. Even though certain symptoms are more likely with a hemorrhagic stroke than a regular stroke, it is not possible to be certain about it. Whenever paramedics evaluate someone with a possible stroke, they call ahead to the ER receiving the patient. The ER gets ready to take you to the CT scanner as soon as you get there. Most well equipped ERs in the United States aim to get a CT scan of the head within 10 minutes.
The goal of the first CT scan is to look for brain bleed. Most regular strokes do not show up on the first CT scan done that early. For practical purposes, all strokes coming into the ER are considered possible strokes from brain bleed unless proven otherwise. The first CT scan is the way to distinguish between the two. If blood is seen in the CT scan, you have a stroke from brain bleed. If there is no blood seen, you have a regular stroke.
Once a hemorrhagic stroke is confirmed, these are the important monitoring and treatment procedures you can expect in the hospital:
- Blood pressure monitoring: The initial treatment is focused on making sure your vitals are stable. It is really important to monitor and keep your blood pressure at a certain level. You may need IV drips that are adjusted continuously to make sure your blood pressure doesn’t go higher or lower than the optimal range.
- Monitoring breathing: They will monitor your oxygen levels, your breathing rate, and your level of consciousness. You may need to be placed on a ventilator if you are unable to protect your airway due to decreased consciousness.
- Watching for seizures: Strokes from brain bleed frequently cause seizures. Seizures are caused by a sudden firing inside the brain that results in involuntary muscle movement. You may need medications to suppress these seizures.
- Looking out for increased pressure inside your brain: Brain bleed can swell up to create high pressure inside your skull. It can crush the vital centers in your brain and lead to death. Worsening headaches, forceful vomiting, and increasing drowsiness are the signs of increased pressure inside the skull. You may need medications to try and lower the pressure. In some cases, you may need invasive monitoring with a small instrument inserted inside your brain.
- Surgical treatment: Neurosurgeons carefully evaluate patients with brain bleed and offer surgical treatment to those who may do well with surgery. Unfortunately, not everyone is a good candidate for surgery.
The outcome of a stroke from brain bleed is not very good. Up to 40% of patients with hemorrhagic strokes don’t make it. Those who survive may need long-term help. Only a fraction of them have full recovery after a prolonged rehab.
In conclusion, a stoke from brain bleed is a very different type of stroke, and it needs hospitalization with close monitoring. The outcome of hemorrhagic strokes are worse than that of regular strokes. Taking care of your high blood pressure and not smoking are the two most important things you can do to prevent a hemorrhagic stroke.
References:
https://www.ahajournals.org/doi/10.1161/01.str.0000130855.70683.c8
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5307940/
https://pubmed.ncbi.nlm.nih.gov/20223391/
https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.107.484139