Stroke, sometimes called "brain attack", is a common and deadly form of cardiovascular diseases that is caused by blocked or ruptured artery that supply the brain with oxygen and nutrient rich blood. There are two types of stroke: ischemic stroke (caused by a clot that clog the blood vessel), and hemorrhagic stroke (occur when a cerebral artery burst or leak).

The bleeding that precede hemorrhagic stroke may either collect inside the brain, or around it. This will create pressure over brain tissue and deprive brain cells of oxygen, which begin to die. The effect of hemorrhagic stroke depends on where the bleeding occurs in the brain and how much the brain is damaged.

Symptoms of hemorrhagic stroke emerge suddenly, and can be notices as a weakness or paralysis of one side of the body. Speaking and thinking May also be affected and the person may have severe headache and/or confusion. These symptoms last usually for more than 24 hours and some may continue for the rest of life if the condition isn’t treated early and/or no habilitation program had been made and followed.

Everyone with suspected stroke should receive a brain scan within 24 hours. The person will undergo Computerized tomography (CT) scan, or Magnetic resonance imaging (MRI). These tests will help to distinguish between stroke subtypes and precisely evaluate it to determine the best treatment. The condition may need for further diagnostic tests, such as blood tests for clotting time and factors, and the tests for carotid artery that passes the neck to the brain.

Hemorrhagic stroke is a life-threatening disease that require immediate intervention. Emergency treatment of hemorrhagic stroke focuses on controlling bleeding and reducing pressure in the brain. Surgery also may be performed to help reduce future risk. Many of treatments of ischemic stroke, such as blood thinners, antiplatelets and thrombolytics are not used with hemorrhagic stroke as they can make the bleeding worse.

As many as 80% of strokes are preventable, thus the person has a choice to protect him/herself from stroke by controlling modifiable risk factors for hemorrhagic stroke. Managing hypertension are among the strongest preventive measures to reduce the risk of hemorrhagic stroke. Quitting smoking and limiting alcohol intake are also helpful.

Hemorrhagic stroke is a disease occurs when a blood vessel bursts or bleeds into or around the brain. The result is blood seeping into the brain tissue or in its surroundings that deprives it from oxygen. When this happens, brain cells begin to die, which will affect functions regulated by the affected area.

• Intracerebral hemorrhage. The most common hemorrhagic stroke happens when a blood vessel inside the brain bursts and leaks into surrounding brain tissue. The bleeding causes brain cells to die and the affected part of the brain stops working correctly. High blood pressure and aging blood vessels are the most common causes of this type of stroke.
• Subarachnoid hemorrhage. This type involves bleeding in the area between the brain and the tissue covering it, known as the subarachnoid space. It is most often caused by a burst aneurysm. Other causes include: arteriovenous malformation, head injuries, and bleeding disorders. This type can cause extensive damage to the brain and is the most lethal of all strokes.

The main cause of hemorrhagic stroke is Hypertension, which can weaken the arteries in the brain and make them prone to split or rupture. The condition can also result from coagulopathies, anticoagulant therapy, and arteriovenous malformations. Factors that may lead to hemorrhagic stroke are discussed below.

Hemorrhagic Stroke can happen to anyone at any time. However, certain factors are known to increase the risk of having this disease, such as:

• High blood pressure. Hypertension is the leading cause of stroke and the most important controllable risk factor for it. More than half of all strokes are caused by uncontrolled hypertension and up to 60% of hemorrhagic strokes are related to High blood pressure.
• Arteriovenous malformation (AVM). AVM is a genetic condition of abnormal connection between arteries and veins and most often occurs in the brain or spine. It can lead to all types of hemorrhagic stroke.
• Traumatic Brain Injury. A bleeding inside or around the brain may occur as a result of hitting the head by accidents or objects that lead to bursting of a blood.
• Blood thinners. Anticoagulant therapy is especially likely to increase hemorrhage risk in patients who metabolize warfarin inefficiently. This drug should be carefully measured before introducing to patient.
• Amyloidosis. Cerebral amyloidosis affects people who are elderly and may cause up to 10% of intracerebral hemorrhages. Amyloidosis is a rare disease that occurs when an abnormal protein called amyloid builds up in organs.
• Bleeding disorders. Coagulopathies may be acquired or inherited. Liver disease can result in an unusual susceptibility to bleed )diathesis(. Inherited disorders of coagulation such as clotting factors deficiency can predispose to excessive bleeding. Intracranial hemorrhage has been seen in all of these disorders.
• Smoking Cigarette. Smoking causes up to a four-fold increase in the risk of hemorrhagic stroke. It has been linked aneurysm formation; an abnormal widening of artery wall that expose it to burst and bleed.
• Excess alcohol intake. Excessive alcohol consumption can lead to high blood pressure and trigger irregular heartbeat called atrial fibrillation, both of which can increase the risk of having a stroke.
• Gender. Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they're more likely to die of strokes than are men. Taking birth control pills and being pregnant also increase the risk among women.
• Aging. Stroke risk increase with age. Studies mentioned by national health institutes, USA, show the risk of stroke doubles for each decade between the ages of 55 and 85. However strokes also can occur in childhood or adolescence.
• Race. Blacks have an age-adjusted risk of death from stroke that is 1.49 times that of whites. Hispanics have a lower overall incidence of stroke than whites and blacks but more frequent lacunar strokes and stroke at an earlier age.

In intracerebral hemorrhage, bleeding occurs directly into the brain tissue. The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension. Intracerebral hemorrhage has a predilection for certain sites in the brain, including the thalamus, putamen, cerebellum, and brainstem. In addition to the area of the brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by the mass effect of the hematoma. A general increase in intracranial pressure may occur.

The hemorrhage can occur beneath the arachnoid matter that surround the brain to be called subarachnoid hemorrhage, which may result in elevated intracranial pressure and impaired cerebral autoregulation. These effects can occur in combination with acute vasoconstriction, microvascular platelet aggregation, and loss of microvascular perfusion, resulting in profound reduction in blood flow and cerebral ischemia, then cell death occur.

The signs and symptoms of a stroke vary from person to person but usually begin suddenly. As different parts of the brain control different parts and functions of body, the symptoms will depend on the part of the brain affected and the extent of the damage. The major manifestations of stroke include:

• Sudden numbness, weakness, or even paralysis of face, arm and leg, especially on one side of the body;
• Sudden confusion or trouble speaking or understanding speech;
• Sudden trouble seeing in one or both eyes;
• Sudden trouble with walking, dizziness, or loss of balance or coordination;
• Sudden severe headache with no known cause. It may be accompanied by vomiting, or altered consciousness.

Having stroke symptoms may indicates that the person is affected by a hemorrhagic stroke. A number of tests can then be carried out to help confirm the diagnosis and determine the cause and severity of the condition. They include:

• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of the brain. A CT scan can show a hemorrhage, tumor, stroke and other conditions. Doctors may inject a dye into the bloodstream to view blood vessels in the neck and brain in greater detail. This procedure is called computerized tomography angiography.
• Magnetic resonance imaging (MRI). An MRI scan uses a strong magnetic field and radio waves to produce a detailed picture for inside the body. This will provide greater detail of brain tissue, allowing smaller, unknown or more unusually located areas affected by a stroke to be identified. A dye may also be used to create more detailed picture.
• Blood tests. If the person is being evaluated for stroke, it is likely that the doctor will order some blood tests. Stroke cannot be diagnosed by a blood test alone. However, these tests can provide information about stroke risk factors and other medical problems which may be important. Coagulation tests, such as PT, PTT, and INR are commonly used. Others include complete blood count (CBC), and blood chemistry tests.
• Swallow tests. A swallow test is essential for anybody who has had a stroke, as swallowing ability is commonly affected early after a stroke, and so food and drink may get into the trachea and then into the lungs (called aspiration), which can lead to pneumonia. In the test, the patient has to be able to swallow a few teaspoons of water without choking and coughing.

Stroke is a medical emergency that need to be treated immediately. Early treatment may minimize the long-term effects of a stroke and prevent death. Different treatments are required for the different types of stroke, so a rapid diagnosis will make treatment more straightforward. Treatment for hemorrhagic stroke include:

• Emergency measures: If the affected person had taken warfarin or other anticoagulant, he may be given drugs or transfusions of blood products to counteract the blood thinners' effects. The patient may also be given drugs to lower pressure in the brain (intracranial pressure), lower blood pressure, prevent vasospasm or prevent seizures. Once the bleeding in or around the brain stops, treatment usually involves supportive medical care while the body absorbs the blood. If the area of bleeding is large, your doctor may perform surgery.
• Surgery: Occasionally, emergency surgery may be needed to remove any blood from the brain and repair any burst blood vessels. This is usually done using a surgical procedure known as a craniotomy. During a craniotomy, a section of the skull is cut away to allow the surgeon access to the cause of the bleeding. The surgeon will repair any damaged blood vessels and ensure there are no blood clots present that may restrict the blood flow to the brain. Surgeries may also be used to repair blood vessel abnormalities associated with hemorrhagic strokes. They include:
• • Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.
  • Endovascular coiling. In this procedure, a surgeon inserts a catheter into an artery in the groin and guides it to the brain using X-ray imaging. The surgeon then directs tiny detachable coils into the aneurysm, which will fill the aneurysm and block blood flow into it.
  • Surgical arteriovenous malformation (AVM) removal. Surgeons may remove a small AVM if it's located in an accessible area of the brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. Deep, large, and complicated AVM removal may be impossible.
  • Intracranial bypass. In some unique circumstances, surgical bypass of intracranial blood vessels may be an option to treat poor blood flow to a region of the brain or complex vascular lesions, such as aneurysm repair.
  • Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair vascular malformations.
• Rehabilitation: After emergency treatment and surgery, stroke care focuses on helping the person recover as much function as possible and return to independent living. The health care providers will try to help the patient to deal with lost functions affected by stroke, or even regain them after long term rehabilitation program. The program may start in the hospital, then to be continued in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or in the patient home. It may involve physical therapy, Speech therapy, diet plan, and/or other therapies required. According to mayo clinic, Researchers have found that the central nervous system is adaptive and can recover some functions of dead cells. They also have found that it's necessary to keep practicing regained skills. Although some stroke survivors recover quickly, most need some form of stroke rehabilitation long term, possibly months or years after their stroke, or even for the rest of life. The duration of stroke rehabilitation depends on the severity of the stroke and related complications.

A stroke can cause temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected. Complications of stroke may include:

• Paralysis or loss of muscle movement. The patient may become paralyzed on one side of the body, or lose control of certain muscles, such as those on one side of the face or one arm. Usual daily activities, such as walking, eating and dressing may become very hard, or even impossible.
• Difficulty contacting. A stroke may cause to have less control over the way the muscles in the mouth and throat move, making it difficult to talk clearly (dysarthria). The person also may have difficulty with understanding speech, reading, or writing, which may hold social interaction.
• Malnutrition. For the same previous reason, stroke patients may not be able to swallow foods and drinks as adequately. This could limit their abilities to get their needs of nutrition and fluid, and so the patient may face dehydration and nutrients deficiencies.
• Memory loss or thinking difficulties. Many people who have had strokes experience some memory loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts.
• Emotional and behavioral problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression, especially with huge disability caused by stroke. They may also become more withdrawn or impulsive.
• Pain. People who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke.
• Sensitive to temperature changes, especially extreme cold. This complication is known as central stroke pain or central pain syndrome. It generally develops several weeks after a stroke, and it may improve over time.

The good news is that 80 percent of all strokes are preventable. Prevention of a first or recurrent stroke is based on treating an individual's underlying risk factors for stroke. Prevention focuses on:

• Managing hypertension. Adhering to healthy habits will help to reduce the risk of having the main cause of hemorrhagic stroke; i.e. hypertension, or aid in controlling blood pressure if the person is affected by it. This may require eating healthy foods, such as fruits, vegetables, whole grains, fish, and nuts, limiting sodium and sugar intake, and being physically active. The patient may need certain prescribed medication to control high blood pressure.
• Give up smoking. Smoking is a risk factors for both two types of stroke. If the person has a trouble quitting smoking on his own, he has to talk with his doctor about programs and products that can help quitting. Support group in hospitals, workplaces, or community groups offer classes to help people quit smoking.

• Stress Management. Learning how to manage stress, relax, and cope with problems can improve emotional and physical health. Meditation, Physical activity and deep breathing are of these helpful techniques that also boosts cardiovascular health, in contrast to bad ways to cope with stress - such as drinking, smoking, or overeating – that worsen the problem inside the arteries.

How a person is affected by hemorrhagic stroke depends on the location and amount of brain damage caused by the stroke, the ability of other healthy areas of the brain to take over functioning for the damaged areas, and rehabilitation. In general, the less damage there is to the brain tissue, the less disability results and the greater the chances of a successful recovery. The person has the greatest chance of regaining the lost abilities during the first few months after a stroke. People who have larger strokes may be permanently paralyzed on one side of their body or lose their ability to speak. More than 2/3 of survivors will have some type of disability, and about half of them will have some long-term problems with talking, understanding, and decision-making.

According to Harvard University, About 30% to 60% of people with an intracerebral hemorrhage die. In those who survive long enough to reach an emergency room, bleeding usually has stopped by the time they are seen by a doctor. Many people with ruptured aneurysms or subarachnoid hemorrhages also do not survive long enough to reach a hospital. Of those who do, about 50% die within the first month of treatment. However, in people with subarachnoid hemorrhages resulting from arteriovenous malformations (AVM), the risk of death is only about 15%.

Nearly a quarter of people who survive an intracerebral hemorrhage experience a major improvement in their symptoms as their bodies naturally and gradually reabsorb the accumulated blood within the brain. Among those who survive a bleeding aneurysm, about 50% suffer long-term neurological problems. People who bleed from an aneurysm or AVM and do not have this problem treated are at risk for having a repeat bleeding event. One out of 5 survivors of subarachnoid hemorrhage will have bleeding again within 14 days and 50% of them will have a repeat bleed within 6 months. When surgery is used to clip a bleeding aneurysm, there is a good chance of success, but there is also a 5% risk of death or long-term disability.

As per world heart federation, 15 million people worldwide suffer a stroke every year. Nearly six million die and another five million are left permanently disabled. By this, Stroke is considered the second leading cause of disability, after dementia. Stroke also is the second leading cause of death worldwide and affects mainly old adults. It is less common in people under 40 years, although it does happen. In young people the most common causes are high blood pressure or sickle cell disease that mainly affects African and Hispanic children.

The incidence of stroke is declining in many developed countries, largely as a result of better control of high blood pressure, and reduced levels of smoking. However, the absolute number of strokes continues to increase because of the ageing population. In the developing world, the incidence of stroke is increasing. The predictions for the next two decades suggest a tripling in stroke mortality in Latin America, the Middle East, and sub-Saharan Africa.

Stroke subtypes vary greatly in different parts of the world and between different races. However, World heart federation estimates that nearly 80% of all strokes are ischemic, and so the remnant 20% are hemorrhagic. Although hemorrhagic stroke is less common that ischemic, it causes 40% of total deaths by stroke, which make hemorrhagic more serious once happened, especially for subarachnoid hemorrhagic stroke.