Hemorrhagic stroke

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Última revisão: 9 Aug 2025

Última atualização: 23 Apr 2025

Hemorrhagic stroke accounts for approximately 10% of strokes.

Computed tomography (CT) or magnetic resonance imaging (MRI), with high sensitivity for intracerebral hemorrhage, are essential in diagnosis.

The primary treatment for people with hemorrhagic stroke involves supportive care and optimization of intracranial hemodynamics.

Surgical resection of intracerebral hematomas may be of benefit in select cases, such as cerebellar hematomas >3 cm in diameter causing brain stem compression or hydrocephalus.

Patients treated in dedicated stroke units have improved survival and reduced disability at 1 year.

Definição

Stroke is an acute neurologic deficit caused by cerebrovascular etiology. It is further subdivided into ischemic stroke and hemorrhagic stroke.

Hemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in intraparenchymal, subarachnoid, and intraventricular hemorrhage.

Intracerebral hemorrhage is further subdivided into primary and secondary etiology: primary spontaneous intracerebral hemorrhage is defined as hemorrhage in the absence of vascular malformations or associated diseases; secondary intracerebral hemorrhage is from an identifiable vascular malformation or as a complication of other medical or neurologic diseases that either impair coagulation or promote vascular rupture.

História e exame físico

Principais fatores diagnósticos

neck stiffness
history of atrial fibrillation
history of liver disease
visual changes
photophobia
sudden onset followed by progression
altered sensation
headache
weakness
sensory loss
aphasia
dysarthria
ataxia
history of hematologic disorder
vertigo
nausea/vomiting
altered level of consciousness/coma
confusion
gaze paresis

Detalhes completos

Fatores de risco

hypertension
advanced age
male sex
Asian, black, and/or Hispanic ethnicity
family history of hemorrhagic stroke
hemophilia
cerebral amyloid angiopathy
sickle cell disease
autosomal dominant mutations in the COL4A1 gene
hereditary hemorrhagic telangiectasia
autosomal dominant mutations in the KRIT1, CCM2, or PDCD10 genes
anticoagulation
illicit sympathomimetic drugs
vascular malformations
smoking
nonsteroidal anti-inflammatory drugs (NSAIDs)
obstructive sleep apnea
diabetes mellitus
heavy alcohol abuse
cerebral vasculitis
thrombocytopenia
long sleep duration and poor sleep quality
Moyamoya disease
pregnancy
leukemia

Detalhes completos

Investigações diagnósticas

Primeiras investigações a serem solicitadas

noncontrast head CT
chemistry panel
CBC
clotting tests
ECG
platelet function test
urine drug screen
pregnancy test in women of childbearing age
liver function test
intracerebral hemorrhage (ICH) score

Detalhes completos

Investigações a serem consideradas

CT angiography and venography
magnetic resonance angiography and venography
conventional (invasive) angiography
MRI brain
MRI brain with diffusion-weighted imaging (DWI) and gradient-echo sequence (GRE)
MRI brain with susceptibility-weighted imaging

Detalhes completos

Algoritmo de tratamento

Inicial

presumed hemorrhagic stroke

AGUDA

noncerebellar bleed: stable and alert

noncerebellar bleed: decompensating

<3 cm cerebellar bleed: alert

>3 cm cerebellar bleed or drowsy/unstable

Colaboradores

Autores

Raisa C. Martinez, MD

Neurocritical Care Unit

Department of Neurosciences

Wellstar Health System, Kennestone

Marietta

Declarações

RCM declares that she has no competing interests.

Agradecimentos

Dr Raisa Martinez would like to gratefully acknowledge Dr Fernando D. Goldenberg, Dr Alejandro Hornik, Dr Eric E. Smith, and Dr T. Dion Fung, the previous contributors to this topic.

Declarações

EES is an author of a number of references cited in this topic. FDG, AH, and TDF declare that they have no competing interests.

Revisores

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke

Boston

Declarações

LRC declares that he has no competing interests.

Julien Morier, MD

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)

Lausanne

Switzerland

Declarações

JM declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022 Jul;53(7):e282-361.Texto completo Resumo

Intercollegiate Stroke Working Party. The National clinical guideline for stroke for the United Kingdom and Ireland. Apr 2023 [internet publication].Texto completo

Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-e467.Texto completo Resumo

Steiner T, Al-Shahi Salman R, Beer R, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais
- Ischemic stroke
- Hypertensive encephalopathy
- Hypoglycemia
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Diretrizes
- Canadian Stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 7th edition
- Clinical guidelines for stroke management
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Folhetos informativos para os pacientes
Stroke caused by a blood clot: preventing another stroke
Stroke: treatment
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Calculadoras
NIH Stroke Score
Mais Calculadoras
Videos
Venepuncture and phlebotomy: animated demonstration
How to perform an ECG: animated demonstration
Mais vídeos
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Hemorrhagic stroke

Resumo

Definição

História e exame físico

Principais fatores diagnósticos

Fatores de risco

Investigações diagnósticas

Primeiras investigações a serem solicitadas

Investigações a serem consideradas

Algoritmo de tratamento

presumed hemorrhagic stroke

noncerebellar bleed: stable and alert

noncerebellar bleed: decompensating

<3 cm cerebellar bleed: alert

>3 cm cerebellar bleed or drowsy/unstable

Colaboradores

Autores

Raisa C. Martinez, MD

Declarações

Agradecimentos

Declarações

Revisores

Louis R. Caplan, MD

Declarações

Julien Morier, MD

Declarações

Peer reviewer acknowledgements

Disclosures

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

Diretrizes

Folhetos informativos para os pacientes

Calculadoras

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice