Hemorrhagic stroke

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The presenting symptoms of stroke are highly variable depending on the mechanism, volume, and location of stroke. Rapid evaluation and diagnostic testing are essential to distinguish between ischemic and hemorrhagic stroke so that appropriate management can be initiated.

Initial evaluation

Initial assessment includes evaluation of the airway (breathing, pulse oximetry, oral pooling of secretions) and circulation (blood pressure [BP], vascular access).[9] A brief history of stroke symptoms and a streamlined neurologic exam are performed at the same time or immediately following medical stabilization.

Rapid identification and treatment of stroke patients may be provided remotely through the use of telemedicine, which improves access to effective healthcare in community hospitals and rural areas without specialized expertise in stroke.[61][62]

Stroke scales

The NIH Stroke Scale is a rapid physical assessment tool for stroke signs. [ NIH Stroke Score Opens in new window ]

The Intracerebral Hemorrhage (ICH) Score is the most widely used severity-of-illness grading scale for prognosticating outcomes early after onset of intracerebral hemorrhage. Elements of the ICH score include:

ICH volume (>30 cm² = 1 point)
Glasgow Coma Score (GCS) (3-4 = 2 points, 5-12 = 1 point)
Intraventricular hemorrhage (yes = 1 point)
Infratentorial ICH location (yes = 1 point)
Age (>80 years = 1 point).[25]

Other useful scales are the Glasgow Coma Scale and FUNC score (prediction of functional outcome in patients with primary intracerebral hemorrhage). Massachusetts General Hospital Stroke Service: FUNC score calculator Opens in new window

Although these scales are used as formal prognostic instruments, a study has shown that early subjective judgment of physicians correlated more closely with 3-month outcome than did the ICH and FUNC scores.[63]

Medical history

The medical history may identify diseases associated with impaired coagulation, including liver disease and hematologic disorders.

A complete medication history is important for identifying patients with anticoagulant-associated hemorrhage.

One meta-analysis of observational studies found that although nonsteroidal anti-inflammatory drugs (NSAIDs) as a single group were not associated with a significantly increased risk of hemorrhagic stroke, a significantly increased risk was observed among users of specific agents (diclofenac and meloxicam).[47]

Statins have been proven not to increase the risk of hemorrhage, and studies have demonstrated better outcome for patients presenting with intracerebral hemorrhage who were using statins prior to admission.[64][65] No relationship has been found between initial intracerebral hemorrhage volume or 24-hour hematoma volume growth and the use of statins at the time of acute intracerebral hemorrhage.[66][67]

Symptoms and signs

In most cases, the symptoms of intracerebral hemorrhage evolve over seconds or minutes. The most common symptoms are:

Limb weakness
Paresthesias or numbness
Dizziness
Vertigo
Nausea/vomiting
Speech difficulty
Visual loss or double vision
Confusion
Headache.

Presenting signs of intracerebral hemorrhage are variable and depend on the brain regions involved.[68] Seizure sometimes occurs at the onset of hemorrhage.[68] Most common findings on neurologic exam are:

Decreased mental status
Partial or total loss of strength in upper and/or lower extremities (usually unilateral)
Fluent or nonfluent language dysfunction
Sensory loss in upper and/or lower extremities (associated with sensory neglect if nondominant hemisphere stroke)
Gaze paresis (often horizontal and unidirectional)
Visual field loss
Dysarthria
Difficulty with fine motor coordination and gait.

There is no sign that reliably distinguishes between intracerebral hemorrhage and ischemic stroke, but intracerebral hemorrhage is more frequently associated with reduced level of consciousness and signs of increased intracranial pressure.[69] Brain stem and cerebellar hemorrhages are more frequently associated with altered level of consciousness, coma, and vomiting than are ischemic strokes.

Subsequent testing

In patients presenting with stroke-like symptoms, urgent neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is recommended to confirm the diagnosis.[9][70][71]

Additional testing is recommended to identify etiology: identifying the underlying cause is important, as survivors of primary intracranial hemorrhage are at higher risk of subsequent recurrent intracranial hemorrhage than of subsequent ischemic stroke or myocardial infarction.[72]

Computed tomography (CT) of brain

Urgent imaging, typically a noncontrast head CT, is mandatory to discriminate between ischemic and hemorrhagic stroke.[71] Many neurologic conditions can mimic stroke, so definitive diagnosis is vital. Noncontrast CT may also be used as a follow-up exam to evaluate for expansion and worsening mass effect.[13] [Figure caption and citation for the preceding image starts]: Intracranial hemorrhage on CT scanMassachusetts General Hospital personal case files; used with permission [Citation ends].
If a hemorrhage is identified, its location and morphology, and presence or absence of associated lesions, such as arteriovenous malformation (AVM), tumor, or signs of infarction, will help identify a possible secondary cause.
Some centers combine CT with CT angiography (CTA), which rapidly excludes the presence of secondary causes such as AVM or aneurysm. CTA has a sensitivity and specificity exceeding 90% compared with catheter arteriography for the identification of these culprit vascular lesions.[13][73][74][75][76] In addition, the presence of hyperdense contrast material in the hematoma bed on postinjection CT images (spot sign) is associated with greater risk of subsequent hematoma expansion.[77][78] A spot sign score predicts hematoma expansion and poor clinical outcomes.[13][79][80][Figure caption and citation for the preceding image starts]: Spot sign on CT angiogram (arrowhead), indicating the presence of hyperdense contrast material within the hematoma bed on postinjection CT; this has been associated with greater risk of subsequent hematoma expansionFoothills Medical Center personal case files; used with permission [Citation ends].
At least one more brain imaging study should be performed after the initial diagnostic CT to assess for expansion and determine the final hematoma size.[9][81]

Blood tests and ECG

Simultaneously, basic blood tests (complete blood count [CBC], electrolytes, blood urea nitrogen [BUN], creatinine, and partial thromboplastin and prothrombin times) and ECG (to rule out cardiac ischemia or arrhythmia) are recommended to exclude hypocoagulability and other comorbid conditions.[9]

Vascular imaging

Acute CTA plus consideration of CT venography (CTV) is recommended to exclude macrovascular causes of cerebral venous thrombosis in the following groups:[9]
- Lobar spontaneous intracerebral hemorrhage and age <70 years, or
- Deep/posterior fossa spontaneous intracerebral hemorrhage and age <45 years, or
- Deep/posterior fossa and age 45 to 70 years without history of hypertension.
Based on clinical experience in practice, acute magnetic resonance angiogram (MRA) plus venography may be considered in the same patient groups if CTA or CTV cannot be obtained (due to inaccessibility or contrast allergy) or if there is concern about renal impairment. MRA may also be useful to exclude underlying vascular malformations if the etiology is uncertain.[13] However, acute MRA plus venography has lower spatial resolution than CTA/CTV.
If there is a high index of suspicion for AVM, but noninvasive imaging is not diagnostic, conventional invasive angiography is recommended.[9][13] Conventional invasive angiography can demonstrate small AVMs that would otherwise be missed by noninvasive techniques, but its routine use has been supplanted in many centers by safer, noninvasive vessel imaging methods.[13] In patients with spontaneous intraventricular hemorrhage and no detectable parenchymal hemorrhage, catheter intra-arterial digital subtraction angiography (DSA) is recommended to exclude a macrovascular cause.[9] In the acute period, catheter arteriography may miss vascular malformations that are detected by repeat arteriography several weeks later.[13][82]

Magnetic resonance imaging (MRI)

Recommended when certain disease processes are part of the differential diagnosis (e.g., vascular malformation, tumor, cerebral infarction, or cerebral sinus/venous thrombosis) that may not be readily apparent on CT.[2][13][83][84] MRI is useful for evaluating alternative etiologies in patients ages <55 years who do not have typical hypertensive hemorrhage.[13][83][85]
A gradient-echo sequence, which is sensitive to susceptibility effects of iron from hemorrhage, is performed to identify whether microbleeds are present. The presence of multiple microbleeds restricted to lobar brain locations suggests a diagnosis of cerebral amyloid angiopathy in the absence of other causes.[15] Cerebral amyloid angiopathy has a worse prognosis for recurrent hemorrhage than other cases of primary intracerebral hemorrhage, and thus it is important to identify.[86] Susceptibility-weighted imaging (SWI) may be more sensitive for identification of microbleeds and small cerebral cavernous malformations than MRI gradient-echo sequence.[87][Figure caption and citation for the preceding image starts]: 80-year-old woman with numerous punctate foci of hypointensity (black dots) on MRI gradient-echo (GRE) sequence (left), suggesting multiple lobar microbleeds caused by cerebral amyloid angiopathy. MRI susceptibility-weighted imaging (SWI) sequence (right) demonstrates numerous additional microbleeds not seen on the GRE sequenceFoothills Medical Center personal case files; used with permission [Citation ends].

Venepuncture and phlebotomy: animated demonstration

How to take a venous blood sample from the antecubital fossa using a vacuum needle.

How to perform an ECG: animated demonstration

How to record an ECG. Demonstrates placement of chest and limb electrodes.

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Hemorrhagic stroke

Approach

Initial evaluation

Subsequent testing