When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Hemorrhagic stroke

Last reviewed: 9 Apr 2025
Last updated: 23 Apr 2025

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

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 Raisa Martinez would like to gratefully acknowledge Dr Fernando D. Goldenberg, 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. FDG, 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.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022 Jul;53(7):e282-361.Full text  Abstract

Intercollegiate Stroke Working Party. ​The National clinical guideline for stroke for the United Kingdom and Ireland. Apr 2023 [internet publication].Full text

Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-e467.Full text  Abstract

Steiner T, Al-Shahi Salman R, Beer R, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Hemorrhagic stroke images
  • Differentials

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

    • Canadian Stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 7th edition
    • Clinical guidelines for stroke management
    More Guidelines
  • Patient information

    Stroke caused by a blood clot: preventing another stroke

    Stroke: treatment

    More Patient information
  • 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