Is a brain bleed the same as a stroke?

Brain Bleeds vs. Strokes: Understanding the Difference

A brain bleed (intracranial hemorrhage) is a type of stroke, specifically a hemorrhagic stroke, but not all strokes are brain bleeds. 1 Strokes are divided into two main categories: ischemic strokes (caused by blocked blood vessels) and hemorrhagic strokes (caused by bleeding blood vessels).

Types of Stroke

Hemorrhagic Stroke (Brain Bleed)

• Definition: Rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood in the brain parenchyma or ventricular system that is not caused by trauma 1
• Types:
  • Intracerebral hemorrhage: Focal collection of blood within brain tissue or ventricles
  • Subarachnoid hemorrhage: Bleeding into the space between the brain and surrounding membranes
  • Subdural and epidural hematomas: Bleeding between layers of tissue surrounding the brain

Ischemic Stroke

• Definition: An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction 1
• Mechanism: Blockage of blood vessels supplying the brain, leading to tissue death from lack of oxygen and nutrients

Clinical Distinctions

Hemorrhagic Stroke Features

• More abrupt onset
• Often accompanied by severe headache
• Frequently involves vomiting
• Higher likelihood of altered consciousness
• Typically presents with:
  • Contralateral hemiparesis
  • Hemisensory loss
  • Homonymous hemianopia 2

Factors Suggesting Hemorrhagic Stroke

• Coma on arrival
• Severe headache
• Vomiting
• Current warfarin therapy
• Systolic blood pressure >220 mm Hg
• Glucose >170 mg/dL in non-diabetic patients 1, 2

Diagnostic Approach

Brain imaging is mandatory to distinguish between ischemic and hemorrhagic strokes, as clinical features alone are insufficient to guide treatment decisions 1. Non-contrast CT scan is recommended immediately (within 25 minutes of arrival) as the first-line diagnostic tool 2.

Pathophysiology and Outcomes

Hemorrhagic Stroke

• Accounts for approximately 15% of all strokes worldwide 3
• Causes include:
  • Hypertensive arteriopathy (deep hemorrhages)
  • Cerebral amyloid angiopathy (lobar hemorrhages)
  • Vascular malformations or aneurysms (especially in young patients) 3
• Higher mortality rate compared to ischemic strokes, with approximately 50% fatality rate 4

Ischemic Stroke

• Accounts for approximately 85% of all strokes 3
• Causes include:
  • Small vessel arteriolosclerosis
  • Cardioembolism
  • Large artery athero-thromboembolism 3

Management Implications

The critical distinction between hemorrhagic and ischemic strokes is essential for treatment decisions:

• Thrombolytic therapy (clot-busting medications) is beneficial for ischemic strokes but potentially fatal in hemorrhagic strokes
• Anticoagulants increase the risk of intracranial hemorrhage 7-10 fold 5
• Hemorrhagic strokes may require surgical intervention in certain cases, particularly for large cerebellar hemorrhages 4

Common Pitfalls

1. Relying solely on clinical features: Clinical findings overlap between stroke types, making imaging mandatory 1
2. Misdiagnosis of stroke mimics: Conditions such as seizures, confusional states, syncope, metabolic disorders, brain tumors, and subdural hematoma can mimic stroke symptoms 1, 2
3. Delayed imaging: Immediate brain imaging is essential for proper diagnosis and treatment planning 2
4. Overlooking "covert" brain lesions: These can be ischemic or hemorrhagic and are often detectable only on specialized MRI sequences 1

In conclusion, while a brain bleed is indeed a type of stroke (hemorrhagic stroke), it represents a distinct pathophysiological process from the more common ischemic stroke. The distinction is crucial for proper management and treatment decisions.