Hemorrhagic stroke

Last reviewed: 22 Aug 2023
Last updated: 03 Feb 2023



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
More key diagnostic factors

Risk factors

  • hypertension
  • advanced age
  • male sex
  • Asian, black, and/or Hispanic ethnicity
  • family history of hemorrhagic stroke
  • hemophilia
  • cerebral amyloid angiopathy
  • 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)
  • diabetes mellitus
  • heavy alcohol abuse
  • cerebral vasculitis
  • thrombocytopenia
  • Moyamoya disease
  • leukemia
More risk factors

Diagnostic investigations

1st investigations 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
More 1st investigations to order

Investigations to consider

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

Treatment algorithm


presumed hemorrhagic stroke


noncerebellar bleed: stable and alert

noncerebellar bleed: decompensating

<3 cm cerebellar bleed: alert

>3 cm cerebellar bleed or drowsy/unstable



Fernando D. Goldenberg, MD

Clinical Associate of Neurology

Medical Director, Neuroscience ICU

Director, Neurocritical Care Education

Co-Director, Stroke Center

University of Chicago




FDG has provided expert testimony in medical legal cases, unrelated to the article topic.

Raisa C. Martinez, MD

Neurocritical Care Unit

Department of Neurosciences

Wellstar Health System, Kennestone




RCM declares that she has no competing interests.


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.


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




LRC declares that he has no competing interests.

Julien Morier, MD

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)




JM declares that he has no competing interests.

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