A SUDDEN onset of severe headache, confusion and slurred speech could be warning signs of an intracranial bleed – a serious and potentially life-threatening condition.
Sunway Medical Centre Damansara consultant neurosurgeon Dr Davendran Kanesen explains that an intracranial bleed is haemorrhaging that occurs inside the skull, either within the brain tissue or in the spaces surrounding the brain.
It is a type of stroke, specifical-ly a haemorrhagic stroke.
This differs from the more common ischaemic stroke, which occurs when a blood vessel is blocked, rather than ruptured.
Intracranial bleeding is a significant contributor to the country’s stroke burden.
“National data show that in 2019, approximately 42,000 stroke cases were recorded, with about 18-20% due to intracerebral haemorrhage,” he notes.
Intracranial bleeding is generally more life-threatening than an ischaemic stroke because the bleeding increases pressure inside the skull and can damage brain tissue rapidly.
What causes intracranial bleeding
Dr Davendran says that there are several common causes of intracranial bleeding, including “uncontrolled hypertension, head trauma, vascular malformations, ruptured cerebral aneurysms, and anticoagulant or antiplatelet medication.
“Other causes include brain tumours and illicit drug use.”
He says uncontrolled high blood pressure is a major risk factor because it weakens small blood vessels in the brain, making them more prone to rupture.
“In Malaysia, hypertension-related bleeds are a leading cause of intracranial bleeding,” he reveals.
A brain aneurysm is a weakened, bulging area in a brain blood vessel wall that can burst and bleed into the brain.
When that happens, it gives the classic symptom described as the thunderclap headache.
“This is a sudden, explosive and extremely severe headache that reaches peak intensity within moments,” he says.
Road traffic accidents, falls (especially among the elderly), and even sports injuries, can all lead to bleeding in or around the brain.
Blood-thinning medications such as anticoagulants and anti-platelet drugs also increase bleeding risk. While these medications are important for preventing clots in high-risk patients, they can make bleeding more severe if it occurs.
Also, some common health supplements can increase the risk of bleeding, especially when taken with prescribed blood thinners.
“Lifestyle factors such as smoking, heavy alcohol consumption and poorly controlled diabetes may all contribute indirectly by damaging blood vessels,” he adds.
Recognising warning signs
Symptoms, Dr Davendran points out, can vary.
“A sudden, severe headache, weakness on one side, slurred speech, confusion, vomiting, headache that resolves with vomiting, seizures or reduced consciousness can be early signs.”
Others may have more subtle symptoms with persistent headaches that deteriorate with the subsequent development of other symptoms.
He advises people to be especially sensitive to elderly individuals who have experienced a fall.
Family members should watch for subtle changes such as increasing forgetfulness, worsening headaches, personality changes, imbalance or unusual sleepiness.
Some patients may even appear well initially, but deteriorate hours, or even days later, as bleeding continues or swelling increases.
“Seek medical help immediately. An urgent CT scan of the brain can detect bleeding within minutes and help determine the type and location of the haemorrhage,” he advises.
A race for time
Rapid diagnosis is crucial because the skull is a closed space and rising pressure from bleeding can damage delicate brain tissue.
Not all intracranial bleeds require surgery.
Small, stable bleeds may be managed with close monitoring, blood pressure control and supportive care in a high-dependency or intensive care unit.
However, surgery is necessary if there is significant pressure on the brain, the bleed is expanding, there is a large clot that needs removal, or an aneurysm needs to be secured.
Neurosurgeons may remove accumulated blood, relieve pressure or repair damaged blood vessels. In cases of aneurysm, specialised procedures such as clipping or endovascular coiling may be performed.
According to Dr Davendran, recovery varies, with some patients making good recovery, particularly if treated early.
Others experience lasting complications such as weakness, speech difficulties, memory problems or seizures.
He stresses that rehabilitation – physiotherapy, occupational therapy and speech therapy – plays a critical role in regaining function, especially in the early stages of recovery.
Prevention matters
Dr Davendran cautions that chronic high blood pressure remains the dominant risk factor for intracranial bleeds, present in over 80% of affected patients.
To reduce risk, he advises avoiding smoking, limiting excessive alcohol intake, managing diabetes and cholesterol, and striving to prevent falls, especially in older adults.
Those on blood thinners should attend regular follow-ups and immediately inform their doctor of any head injury, even minor ones.
He stresses: “Never ignore a sudden severe headache or new neurological symptom.
“Early treatment can be lifesaving and can prevent permanent disability.”
