Hemorrhagic stroke (summary)

This is a basic article for medical students and other non-radiologists

Hemorrhagic stroke is a clinical diagnosis where an acute neurological deficit follows a bleed into the brain parenchyma.

Reference article

This is a summary article; read more in our article on intracerebral hemorrhage.

Summary

• epidemiology

  • common, and accounts for 20% of stroke overall ¹, although is more common in Asian countries

    • the other 80% is ischemic stroke

  • a leading cause of disability

• presentation

  • sudden focal neurological deficit whereby the exact clinical features depend on where the hemorrhage is within the brain ¹

  • reduced conscious state, headache, and seizures may also be present ¹

• pathophysiology

  • most commonly caused by a spontaneous rupture of small blood vessels within the brain, causing an intracerebral hemorrhage ¹

    • location of the intracerebral hemorrhage may assist with etiology

      • deep (centrally-located, or infratentorially-located): hypertensive microangiopathy is the most common cause ¹

      • lobar (peripherally within cerebral hemispheres): cerebral amyloid angiopathy is the most common cause ¹

  • less commonly may be due to a vascular malformation, tumor, cerebral venous sinus thrombosis, or other rarer secondary pathology ²

  • intracerebral hemorrhage due to trauma is not considered to be a hemorrhagic stroke

• investigation

  • non-contrast CT head in the first instance

    • shows intracerebral hemorrhage and associated complications ²

  • CT angiography

    • some centers use this to identify any contrast entering the area of hemorrhage (spot sign) which may indicate hematoma expansion ²

    • may also be used to identify any vascular malformations

  • contrast-enhanced CT

    • some centers use this to identify any underlying tumors ²

  • MRI

    • less commonly used acutely in most centers, but may be performed in some centers months after the stroke to identify any secondary cause ²

• treatment

  • all patients with stroke should be managed in a dedicated stroke unit where possible, with input from the local stroke and neurosurgery services ⁴

  • acute treatment ⁴

    • strict control of blood pressure with antihypertensive medications

    • reversal of any anticoagulation or coagulopathy

    • management of raised intracranial pressure, with medical and surgical options

    • neurosurgical hematoma evacuation can be considered on a case-by-case basis ⁵

  • secondary prevention depends on underlying cause, e.g. long-term management of hypertension, review of anticoagulation ⁴

Imaging

• role of imaging

  • is there evidence of intracerebral hemorrhage?

  • is the hemorrhage lobar or deep in location?

  • is there evidence of active hematoma expansion?

  • is there evidence of dangerous mass effect?

  • is there evidence of intraventricular extension of the hemorrhage?

  • is a cause immediately visible, e.g. vascular malformation or tumor?

• radiographic features

  • CT

    • intracerebral hemorrhage is readily visible as hyperdense and its volume can be calculated ²

    • around the hemorrhage, there may be surrounding hypodense edema ²

    • mass effect and other complications may be visible, such as midline shift, hydrocephalus or uncal herniation ²

    • subtle features of hematoma expansion may be present ³

  • angiography (CTA/MRA/DSA)

    • may assist with determining whether there is likelihood of hematoma expansion ²

    • may identify underlying vascular malformations ²

  • contrast-enhanced CT

    • some centers use this to identify any underlying tumors, although MRI is a better imaging modality for this

  • MRI

    • often performed in a delayed fashion, once the hematoma has resolved, to determine the cause of the hemorrhage ²

    • can identify tumors, vascular malformations, and evidence of cerebral small vessel diseases (e.g. hypertensive microangiopathy, cerebral amyloid angiopathy) ²