Hemorrhagic stroke

Last reviewed: 3 May 2023
Last updated: 03 Feb 2023
02 Nov 2022

Updated US guidelines based on findings from several clinical trials: some management strategies for spontaneous hemorrhagic stroke are not as effective as previously believed

The American Heart Association/American Stroke Association have updated their 2015 guidance on the management of intracerebral hemorrhage; key new and updated aspects include:

  • Acute computed tomography angiography (CTA) is recommended, with consideration of CT venography (CTV), to exclude macrovascular causes of cerebral venous thrombosis, in the following groups:

    • Lobar spontaneous intracerebral hemorrhage, age <70 years, or

    • Deep/posterior fossa spontaneous intracerebral hemorrhage, age <45 years, or

    • Deep/posterior fossa, age 45 to 70 years, without history of hypertension.

  • Antihypertensive medications should be carefully titrated in patients with spontaneous intracerebral hemorrhage requiring acute blood pressure lowering. This is to ensure continuous smooth and sustained control of blood pressure (BP), avoiding peaks and large variability in systolic BP.

  • In nonambulatory patients, intermittent pneumatic compression should be started on the day of intracerebral hemorrhage diagnosis for deep venous thrombosis (DVT) prophylaxis. Graduated knee- or thigh-high compression stockings are ineffective in preventing DVT in this patient group.

  • Platelet transfusions are not recommended for patients with spontaneous intracerebral hemorrhage being treated with aspirin and not scheduled for emergency surgery. Outside the setting of emergency surgery or severe thrombocytopenia, routine use appears to worsen outcome.

  • In patients with vitamin K antagonist-associated spontaneous intracerebral hemorrhage and international normalized ratio (INR) ≥2.0, 4-factor prothrombin complex concentrate is preferable to fresh-frozen plasma for rapid correction of INR and to limit hematoma expansion.

  • For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without external ventricular drain (EVD) now include cerebellar intracerebral hemorrhage volume ≥15 mL in addition to previously recommended indications of neurologic deterioration, brainstem compression, and hydrocephalus. Surgical intervention in these patients has been shown to reduce mortality, compared with medical management alone.

  • Early aggressive mobilization within the first 24 hours following intracerebral hemorrhage should be avoided since this appears to worsen 14-day mortality.

See Diagnosis: approach

See Management: approach

Original source of update



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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