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Hemorrhagic stroke

Last reviewed: 5 Oct 2024
Last updated: 12 Mar 2024

Summary

Definition

History and exam

Key diagnostic factors

  • 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
Full details

Risk factors

  • 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
Full details

Diagnostic tests

1st tests to order

  • 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
Full details

Tests to consider

  • 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
Full details

Treatment algorithm

INITIAL

presumed hemorrhagic stroke

ACUTE

noncerebellar bleed: stable and alert

noncerebellar bleed: decompensating

<3 cm cerebellar bleed: alert

>3 cm cerebellar bleed or drowsy/unstable

Contributors

Authors

Fernando D. Goldenberg, MD

Clinical Associate of Neurology

Medical Director, Neuroscience ICU

Director, Neurocritical Care Education

Co-Director, Stroke Center

University of Chicago

Chicago

IL

Disclosures

FDG declares that he has no competing interests.

Raisa C. Martinez, MD

Neurocritical Care Unit

Department of Neurosciences

Wellstar Health System, Kennestone

Marietta

GA

Disclosures

RCM declares that she has no competing interests.

Acknowledgements

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

Disclosures

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

Peer reviewers

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke

Boston

MA

Disclosures

LRC declares that he has no competing interests.

Julien Morier, MD

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)

Lausanne

Switzerland

Disclosures

JM declares that he has no competing interests.

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