“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".
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 our topics Ischaemic stroke, Subarachnoid haemorrhage, and Cavernous sinus thrombosis.
History and exam
- older age
- male sex
- Asian, black and/or Hispanic
- heavy alcohol use
- illicit sympathomimetic drugs
- family history of intracerebral haemorrhage
- cerebral amyloid angiopathy
- autosomal dominant mutations in the COL4A1 gene
- hereditary haemorrhagic telangiectasia
- autosomal dominant mutations in the KRIT1 gene, CCM2 gene, or PDCD10 gene
- vascular malformations
- Moyamoya disease
- non-steroidal anti-inflammatories (NSAIDs)
- diabetes mellitus
- sympathomimetic medications
- cerebral vasculitis
Greater Manchester Neurosciences Centre
Salford Royal Foundation Trust
Honorary Senior Lecturer
University of Manchester
MJ declares that he has no competing interests.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributors, whose work has been retained in parts of the content:
Fernando D. Goldenberg, MD
Clinical Associate of Neurology
Medical Director, Neuroscience ICU
Director, Neurocritical Care Education
Co-Director, Stroke Center
University of Chicago
Raisa C. Martinez, MD
Neurocritical Care Fellow
Department of Neurology
University of Chicago
FDG and RCM declare that they have no competing interests.
Professor of Clinical Neurology
Head of Research Department, Brain Repair and Rehabilitation
UCL Institute of Neurology
Honorary Consultant Neurologist
National Hospital for Neurology and Neurosurgery
University College Hospitals NHS Foundation Trust
North Thames Clinical Research Specialty Lead for Stroke
NIHR Clinical Research Network
DW has received honoraria (speaking) from Bayer 2016, 2017, 2018 (talks or debates on intracerebral haemorrhage, atrial fibrillation, dementia) and honoraria (chairing) from Portola and Bayer 2019. DW has received consultancy fees from Bayer (2017; embolic stroke of undetermined source), JFB consulting (2018; PCSK9 inhibitors in stroke), Alnylam (2019; cerebral amyloid angiopathy), Portola (2019, 2020; andexanet alpha). JW was UCL Principle Investigator for NIHR clinical trials NAVIGATE-ESUS (Bayer, 2016-19), B2341002 (Pfizer 2014-2016), Action-2 (Biogen, 2016-19); Chief Investigator for OPTIMAS; steering committee and co-investigator for RESTART, TICH-2.
Section Editor, BMJ Best Practice
HDC declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
TAO declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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