Stroke due to spontaneous intracerebral haemorrhage

Stroke due to spontaneous intracerebral haemorrhage is an emergency.

“Time is brain”. If you suspect stroke, work rapidly through the initial assessment and aim for quick access to computed tomography (CT) scan. CT enables quick differentiation between ischaemic stroke and spontaneous intracerebral haemorrhage (ICH), which must be done before reversing anticoagulation in anticoagulation-induced ICH and before starting thrombolysis in ischaemic stroke. Both are critical and urgent interventions.

Use a validated tool to aid recognition: use ROSIER (Recognition of Stroke in the Emergency Room) in the emergency department; use FAST (Face Arm Speech Test) in the community.

Manage any airway, breathing, and circulatory insufficiencies requiring urgent treatment.

Request an immediate non-enhanced CT scan (i.e., ideally in the next available time slot and definitely within 1 hour of arrival at hospital) if indicated. A CT-scan will confirm the diagnosis of ICH (i.e., presence of hyperattenuation suggesting acute blood).

Prioritise rapid admission of the patient directly to a hyperacute or acute stroke unit (UK guidelines recommend doing this within 4 hours of presentation to hospital); review by a neurosurgeon; reversal of clotting abnormalities, if indicated; lowering of blood pressure, if indicated.

The World Health Organization defines stroke as “a clinical syndrome consisting of rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin".[1]Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ. 1980;58(1):113-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395897 http://www.ncbi.nlm.nih.gov/pubmed/6966542?tool=bestpractice.com

Stroke can be subdivided into ischaemic stroke (caused by vascular occlusion or stenosis) and haemorrhagic stroke (caused by vascular rupture, resulting in intracerebral [intraparenchymal], subarachnoid, or intraventricular haemorrhage). Central venous sinus thrombosis is a rare form of stroke that occurs due to thrombosis of the dural venous sinuses.

Most intracerebral haemorrhages occur in the absence of vascular malformations, aneurysms, or other structural causes, and are presumed to be due to diseases affecting small cerebral vessels (arteriolosclerosis or cerebral amyloid angiopathy); this is often called primary intracerebral haemorrhage (ICH) but this term discourages adequate investigation and accurate diagnosis so is not recommended. ICH from an identifiable vascular malformation or as a complication of other medical or neurological diseases that either impair coagulation or promote vascular rupture is termed secondary ICH.

This topic focuses on the first 24 hours of acute care of patients with a stroke due to spontaneous ICH. For information on other types of stroke, see  Ischaemic stroke,  Subarachnoid haemorrhage, and Cavernous sinus thrombosis.