Definition of Hemorrhagic Stroke
Hemorrhagic stroke is a life-threatening neurological emergency that occurs when the integrity of cerebral blood vessels is disrupted, leading to bleeding into the intracranial space. This bleeding may involve the brain tissue (intracerebral hemorrhage, ICH), the subarachnoid space between the brain and its protective membranes (subarachnoid hemorrhage, SAH), or the ventricular system (intraventricular hemorrhage, IVH). As a result, patients may develop increased intracranial pressure, brain tissue compression, secondary ischemic injury, and cerebral edema.
When we talk about define hemorrhagic stroke, it can be summarized as: bleeding inside or around the brain caused by ruptured blood vessels, resulting in acute neurological decline and a high risk of disability or death.
Epidemiology
Hemorrhagic strokes account for approximately 10–15% of all strokes.
ICH is the most common subtype, typically occurring in older adults with a history of chronic hypertension.
SAH accounts for fewer than 5% of all strokes but carries a high mortality and morbidity rate, even in younger patients.
IVH usually develops as an extension of ICH into the ventricles. Primary IVH is rare but represents a major cause of morbidity in premature newborns.
Risk Factors
The development of hemorrhagic stroke is influenced by genetic, environmental, and medical conditions:
Cardiovascular factors: Chronic hypertension (the most significant cause), hyperlipidemia, diabetes mellitus.
Medications and hematologic disorders: Anticoagulant or antiplatelet therapy, hemophilia, thrombocytopenia, coagulopathies.
Vascular pathologies: Cerebral aneurysms, arteriovenous malformations (AVM), cavernous malformations, cerebral amyloid angiopathy (particularly in the elderly).
Trauma and external factors: Head trauma, drug abuse (cocaine, amphetamines).
Lifestyle factors: Obesity, sedentary lifestyle, smoking, alcohol consumption.
Etiology
1. Intracerebral Hemorrhage (ICH)
Hypertensive vasculopathy: chronic hypertension causes lipohyalinosis and microaneurysm formation.
Anticoagulant/antiplatelet use and coagulopathies.
Cerebral amyloid angiopathy (common cause of lobar hematomas in the elderly).
Brain tumors or metastases.
Vascular malformations (AVM, cavernomas).
2. Subarachnoid Hemorrhage (SAH)
Aneurysm rupture (most common cause).
AVMs or other vascular anomalies.
Traumatic SAH.
3. Intraventricular Hemorrhage (IVH)
Most often occurs when ICH extends into the ventricles.
Fragility of the germinal matrix in premature infants.
Anticoagulant use or coagulopathies.
Traumatic causes.
Clinical Presentation
Symptoms vary depending on the type and location of bleeding but are usually sudden in onset and rapidly progressive:
General symptoms:
Severe headache (classically described in SAH as “the worst headache of life”)
Nausea and vomiting (due to increased intracranial pressure)
Altered consciousness (from confusion to coma)
Seizures
Focal neurological deficits:
Hemiparesis/hemiplegia
Sensory loss
Speech disturbances (aphasia, dysarthria)
Visual disturbances (hemianopia, diplopia)
IVH-specific signs: rapid loss of consciousness, headache, hydrocephalus-related gait imbalance.
Diagnostic Methods
Computed Tomography (CT) – First-line tool for emergency diagnosis. Acute hemorrhage appears hyperdense. CT angiography can detect aneurysms and AVMs.
Magnetic Resonance Imaging (MRI / MRA) – More sensitive for small hematomas and subacute or chronic bleeding. Also useful for assessing tissue damage, edema, and concurrent ischemia.
Digital Subtraction Angiography (DSA) – Gold standard for diagnosing aneurysms, AVMs, and other vascular abnormalities.
Additional tools:
Transcranial Doppler for vasospasm monitoring after SAH.
ICP monitoring in intensive care for intracranial pressure assessment.
Treatment Approaches
General Principles
Intensive care unit monitoring.
Blood pressure control (target systolic 130–150 mmHg).
Reversal of anticoagulant/antiplatelet effects.
Intracranial pressure reduction.
Seizure prophylaxis.
1. Intracerebral Hemorrhage (ICH)
Surgical Management: Craniotomy with hematoma evacuation for large hematomas (>30 ml) or lesions causing midline shift.
Minimally invasive for small hematoma; stereotactic aspiration or endoscopic evacuation.
Decompressive Craniectomy: It can be performed in cases of massive hemispheric hematomas with refractory intracranial pressure elevation or significant midline shift. Purpose: To reduce intracranial pressure and prevent herniation.
Medical Management: Blood pressure control.
Reversal of anticoagulant effects.
Osmotic therapy for cerebral edema.
2. Subarachnoid Hemorrhage (SAH)
Securing the bleeding source: The surgical treatment approach varies depending on the cause and amount of bleeding, as well as the patient’s clinical condition.
For information about aneurysms, visit: elmacineuro.com/treatment/cerebral-aneurysms/
For information about arteriovenous malformations, visit: elmacineuro.com/treatment/arteriovenous-malformations/
For information about cavernous malformations, visit: elmacineuro.com/treatment/cavernous-malformations/
Endovascular Coil Embolization: Today, it is the first-line emergency treatment for ruptured aneurysms in SAH. A catheter is inserted into the vessel through the groin, and a metal coil is placed inside the aneurysm to stop blood flow. This method reduces surgical risks, especially in deep, hard-to-reach, or elderly patients.
Surgical Clipping: A small window is opened in the skull (craniotomy) through open surgery. The aneurysm neck is identified, and a metal clip is placed over it to prevent rebleeding. This method is preferred for superficial, large, or complex aneurysms. If a hematoma is present, it can be evacuated at the same time.
Medical Management: Triple-H Therapy (Hypertension, Hypervolemia, Hemodilution) in vasospasm treatment.
Careful fluid balance to avoid cerebral edema.
Seizure prophylaxis, ICP control.
Complication Monitoring: Transcranial Doppler for vasospasm.
“Fisher Grade” used to predict vasospasm risk.
Fisher Grade | CT Findings | Clinical Significance |
|---|---|---|
Grade 1 | No subarachnoid blood or thin layer (<1 mm) | Low risk of vasospasm |
Grade 2 | Diffuse or localized subarachnoid blood >1 mm thick, no intraventricular or intraparenchymal hemorrhage | Moderate risk of vasospasm |
Grade 3 | Localized or thick subarachnoid clot (>1 mm) | High risk of vasospasm |
Grade 4 | Subarachnoid blood with intraparenchymal or intraventricular hemorrhage | High risk of vasospasm, more complications |
3. Intraventricular Hemorrhage (IVH)
External Ventricular Drainage (EVD): for hydrocephalus management.
Intraventricular fibrinolysis (e.g., rt-PA) may be applied in some centers.
Supportive care: ICP control, electrolyte balance, antiepileptic prophylaxis.
Conclusion
Hemorrhagic strokes are severe neurological emergencies requiring rapid diagnosis and aggressive treatment. While management strategies differ for ICH, SAH, and IVH, the core objectives remain the same: halt bleeding progression, control intracranial pressure, and prevent secondary brain injury.
A multidisciplinary approach—neurology, neurosurgery, neuroanesthesia, interventional neuroradiology and intensive care—significantly improves survival rates and functional outcomes.
In summary, the definition of hemorrhagic stroke is intracranial bleeding that leads to acute neurological decline, high morbidity, and mortality. Early recognition and intervention are critical to saving lives and improving recovery.