Hemorrhagic stroke

Last reviewed: 6 Sep 2022
Last updated: 07 Jun 2022

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
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

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

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.

  • Hemorrhagic stroke images
  • Differentials

    • Ischemic stroke
    • Hypertensive encephalopathy
    • Hypoglycemia
    More Differentials
  • Guidelines

    • Guideline for the prevention of stroke in patients with stroke and transient ischemic attack
    • Clinical guidelines for stroke management
    More Guidelines
  • Patient leaflets

    Stroke caused by a blood clot: preventing another stroke

    Stroke: treatment

    More Patient leaflets
  • Calculators

    NIH Stroke Score

    More Calculators
  • Videos

    Venepuncture and phlebotomy: animated demonstration

    How to perform an ECG: animated demonstration

    More videos
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer