Brain haemorrhage (bleed on the brain): symptoms, causes and treatment

The Stroke Association says the symptoms of a haemorrhagic stroke depend on where the bleed happens in the brain. They may include any of the signs of stroke in the FAST test: face weakness, arm weakness or speech problems, with time to call 999. They can also include a sudden, severe headache, sometimes called a thunderclap headache, which people describe as the worst pain ever, like being hit on the head. It is very likely with a subarachnoid haemorrhage but can also happen with an intracerebral haemorrhage.

The NHS lists the main symptoms of a subarachnoid haemorrhage as an extremely painful headache that starts suddenly and does not go away, neck pain or a stiff neck, feeling and being sick, being very sensitive to light, having a seizure, fainting, feeling sleepy or confused, and drooping on one side of the face, slurred speech or weakness on one side of the body. The NHS adds that a subarachnoid haemorrhage can happen at any time but may be more likely when you are coughing, going to the toilet, lifting something heavy or having sex.

• A sudden, extremely painful headache that does not go away.

• Face drooping on one side, or difficulty smiling.

• Weakness or numbness in one arm or down one side of the body.

• Slurred speech, confusion or difficulty finding words.

• Blurred vision or loss of sight in one or both eyes.

• Neck pain or stiffness, being sick, and sensitivity to light.

• A seizure, or drowsiness and loss of consciousness.

Stroke is a medical emergency and the Stroke Association says you should always call 999 if you have any stroke symptoms. The NHS says to call 999 if you or someone you are with gets a sudden headache that is extremely painful and does not go away, has face weakness, weakness or numbness in one arm or down one side of the body, has speech problems, or gets blurred vision or loss of sight. Do not drive yourself to A&E: the person you speak to at 999 will give you advice about what to do.

After a head injury, the NHS lists signs of a subdural haematoma, a bleed inside the skull that can start straight away or come on gradually over a few weeks. Call 999 if someone has hit their head and has been knocked out and has not woken up, has difficulty staying awake, has a fit, has problems with vision or hearing, has numbness or weakness, has problems with walking, balance, understanding or speaking, or has clear fluid coming from the ears or nose. Go to A&E after a head injury if there is vomiting, a headache that does not go away with painkillers, a change in behaviour or problems with memory, or if the person takes blood-thinning medicine.

The Stroke Association says there are two main types of haemorrhagic stroke, which are very different and have different causes. The NHS describes a third pattern, a subdural haematoma, which is bleeding inside the brain usually caused by a head injury.

For intracerebral haemorrhage, the Stroke Association names cerebral small vessel disease. In one type, long-term high blood pressure damages the small, deep blood vessels in the brain, making them stiffen so that their walls become fragile and prone to bleeding. The other common type, especially in older people, is cerebral amyloid angiopathy, where a protein called amyloid beta builds up inside small blood vessels near the surface of the brain, making them more likely to bleed. Rare abnormalities of blood vessels, such as an arteriovenous malformation (a tangle of vessels) or a cavernous malformation, can also cause a bleed.

For subarachnoid haemorrhage, the NHS says the commonest cause is a brain aneurysm, a bulge in a blood vessel. Some people have them from birth while others develop them later, and you may be more likely to have one if others in your family do. Most brain aneurysms do not cause problems, but if one bursts it can cause a subarachnoid haemorrhage. The Stroke Association lists conditions that can make an aneurysm more likely, including adult polycystic kidney disease, connective tissue disorders such as Ehlers-Danlos syndrome and Marfan syndrome, and coarctation of the aorta, and also smoking, high blood pressure, cocaine use and severe head injury.

The NHS says the risk of stroke generally increases if you are over 50, from a Black or South Asian background, have sickle cell disease, have high blood pressure, diabetes, atrial fibrillation or high cholesterol, smoke, or are pregnant with pre-eclampsia. These are risk factors for stroke in general.

The Stroke Association says that if you have a haemorrhagic stroke you will have a brain scan and emergency treatment, followed by support for recovery, including medical prevention treatment and rehabilitation.

The NHS says that how a subarachnoid haemorrhage affects your life depends on where in the brain the bleeding happened and the amount of damage. Although it can take months or years to get better, most people improve with treatment and some recover fully. But it is a very serious condition that can lead to mental and physical disability. You may have seizures, heart, lung or liver problems, difficulty with memory, concentration and communication, depression and mood changes, fatigue, and headaches or unusual feelings such as water trickling in the head. A small number of people develop epilepsy.

The Stroke Association says rehabilitation should begin in hospital soon after a stroke and carry on at home for as long as you need it, with therapists helping you set goals. The NHS lists physiotherapy, speech and language therapy, CBT for mood changes and cognitive exercises. For a subdural haematoma the NHS says that even with the best care there is a high risk of death, and people with serious subdural haematomas can be left with long-term problems with walking, talking and thinking.

A suspected brain haemorrhage is treated as an emergency through 999, with emergency scanning and treatment in an NHS hospital, and specialist stroke or neurosurgical care where needed. Rehabilitation continues in hospital and in the community. The Stroke Association helpline offers support, and private rehabilitation or neurology appointments are available for people who want extra input once the emergency phase has passed. Whichever route you use, ask who coordinates your follow-up and how your blood pressure and other risk factors will be reviewed.