Last reviewed: 7 Apr 2021
Last updated: 17 Dec 2020



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

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

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

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

Treatment algorithm


Clinical Associate of Neurology

Medical Director, Neuroscience ICU

Director, Neurocritical Care Education

Co-Director, Stroke Center

University of Chicago




FDG declares that he has no competing interests.

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 reviewersVIEW ALL

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.

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)




JM declares that he has no competing interests.

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