History and exam
Key diagnostic factors
common
neck stiffness
Hemorrhagic stroke can frequently give rise to neck stiffness. Most commonly seen with subarachnoid hemorrhage due to blood causing meningeal irritation.
history of atrial fibrillation
While not a risk per se, patients with atrial fibrillation are often treated with warfarin and other direct thrombin inhibitors, increasing the likelihood of brain hemorrhage.
history of liver disease
May impair coagulation processes, leading to hemorrhage.
visual changes
Hemianopia may result from hemorrhage in the visual pathways, including the occipital lobe.
Diplopia may result from brain stem hemorrhage.
photophobia
Hemorrhagic stroke can often cause the patient to report photophobia.
sudden onset followed by progression
Intracranial hemorrhage symptoms often start suddenly and progress over several minutes.
Symptoms of ischemic stroke may, in contrast, be maximal at onset, particularly in embolic infarction.
Symptoms that spontaneously improve or resolve suggest ischemia rather than hemorrhage.
altered sensation
Patients often describe sensory loss and paresthesias as numbness.
headache
Usually of insidious onset and gradually increasing intensity in intracerebral hemorrhage.
More common in hemorrhagic stroke than in ischemic stroke, but the absence of headache does not rule out the diagnosis.[3]
Sudden onset with gradual moderation or "most severe headache of my life" (thunderclap headache) suggests subarachnoid hemorrhage.
weakness
Complete or partial loss of muscle strength in face, arm, and/or leg is among the most common stroke presentations.
As with most stroke signs and symptoms, bilateral involvement is uncommon and may reflect alternative etiology.
sensory loss
Cortical sensory loss usually impairs fine sensory processing abilities such as 2-point discrimination, graphesthesia, or stereognosis.
Thalamic hemorrhages can present with sensory loss and pseudoathetosis.
aphasia
Impairment in any language function (fluency, naming, repetition, comprehension) is a sign of dominant hemispheric stroke.
dysarthria
May accompany facial weakness or cerebellar dysfunction.
ataxia
In the absence of muscle weakness, impaired coordination points to hemorrhage involving the cerebellum or its connections with the rest of the brain.
uncommon
history of hematologic disorder
A bleeding diathesis, especially untreated, may lead to hemorrhage.
vertigo
Typically seen in cerebellar hemorrhage.
nausea/vomiting
May be due to posterior circulation hemorrhage or reflect increased intracranial pressure.
With cerebellar hemorrhage, nausea and vomiting may be the only presenting symptom with an unremarkable neurologic exam except for gait ataxia.
altered level of consciousness/coma
Reduced alertness may accompany large hemispheric hemorrhages or posterior fossa hemorrhages.
Prompts higher level of urgency from diagnostic (rule out hemorrhage) and management (breathing and airway protection) standpoints.
Coma is more common with brain stem hemorrhage.
Conditions mimicking stroke (e.g., seizures) need to be excluded.
confusion
Common, especially in older people with previous strokes or cognitive dysfunction.
Fluent, nonrepetitive (Wernicke) aphasia has to be differentiated from confusion, as aphasia is a specific sign of dominant hemisphere injury.
gaze paresis
Often horizontal and unidirectional.
Risk factors
strong
hypertension
male sex
Associated with increased incidence of intracerebral hemorrhage, although the difference lessens with age.[10]
Asian, black, and/or Hispanic ethnicity
family history of hemorrhagic stroke
Epidemiologic studies show a significant portion of sporadic intracerebral hemorrhage risk is heritable, and that family history of intracerebral hemorrhage is a risk factor.[27]
hemophilia
Hereditary bleeding disorders, including hemophilia, may be complicated by intracerebral hemorrhage.
cerebral amyloid angiopathy
Sporadic cerebral amyloid angiopathy (CAA), a common age-related cerebral small vessel disease, is an important cause of lobar ICH, particularly in older people.[32] The risk of recurrent ICH in patients with CAA is approximately 7% per year compared to about 1% for ICH associated with arteriolosclerosis.[32][33] Most cases of cerebral amyloid angiopathy (CAA) are nonfamilial. CAA can rarely be caused by autosomal dominant mutations involving the amyloid precursor protein, cystatin-C, or transthyretin genes.[16]
Additional nonmodifiable risk factors for recurrent primary lobar hemorrhage have been identified in people with presumed CAA: number of MRI microbleeds, presence of white matter lesions on CT, and the presence of one or more apolipoprotein E epsilon 2 or epsilon 4 alleles.[14][34][35][36]
sickle cell disease
The incidence rate of hemorrhagic stroke in patients with sickle cell anemia increases with age. Structural vascular abnormalities such as moyamoya arteriopathy and aneurysms are common etiologies for hemorrhage.[37]
autosomal dominant mutations in the COL4A1 gene
Rare autosomal dominant mutations in the COL4A1 gene cause intracerebral hemorrhage, retinal hemorrhages, and porencephaly (cyst or cavity in the cerebral hemispheres).[38]
hereditary hemorrhagic telangiectasia
Caused by mutations in the ACVRL1, ENG, or SMAD4 gene. High prevalence of brain arteriovenous malformations (AVMs), which in turn increases the risk of intracerebral hemorrhage.[18]
autosomal dominant mutations in the KRIT1, CCM2, or PDCD10 genes
May lead to cavernous malformations.
anticoagulation
illicit sympathomimetic drugs
vascular malformations
These include arteriovenous malformations (AVMs), dural arteriovenous fistulas, and cavernous malformations.[44]
The risk of bleeding depends on the type of malformation, pattern of venous drainage, and history of previous bleeds.
Moyamoya disease
Moyamoya syndrome and Moyamoya disease are associated with parenchymal and intraventricular hemorrhage, predominantly in pediatric patients. The rebleeding rate is approximately 7% per year.[55] Patients with this vasculopathy also have an increased risk for cerebral aneurysms.
pregnancy
The risk of nontraumatic ICH is increased during pregnancy and the postpartum period. One retrospective review showed 6.1 pregnancy-related ICH per 100,000 deliveries and 7.1 pregnancy-related ICH per 100,000 at-risk person-years (compared to 5.0 per 100,000 person-years for nonpregnant women in the same age range).[56] The increased risk of ICH associated with pregnancy is largely attributable to ICH occurring in the postpartum period.[56][57] Peripartum angiopathy, eclampsia, HELLP syndrome, and sinus venous thrombosis can cause ICH in pregnant women.[9] Preexisting risk factors associated with ICH include increasing maternal age, nonwhite race, and chronic hypertension.[57]
weak
smoking
nonsteroidal anti-inflammatory drugs (NSAIDs)
As a single group, NSAIDs did not have significant correlation with higher incidence of intracerebral hemorrhage, although among users of specific agents (diclofenac and meloxicam) a significant increased risk was observed.[47]
obstructive sleep apnea
Severe obstructive sleep apnea doubles the risk for incident stroke, especially in young to middle-aged people. Continuous positive airway pressure (CPAP) may reduce stroke risk, but trials have not provided a high level of evidence to support the benefits of CPAP for primary stroke prevention.[48][49]
diabetes mellitus
heavy alcohol abuse
Associated with an increased risk of hemorrhagic stroke.[52] Light to moderate alcohol consumption may be protective against ischemic stroke but not hemorrhagic stroke.
cerebral vasculitis
Although a relatively infrequent cause of intracerebral or subarachnoid hemorrhage, cerebral vasculitis should be considered in the setting of relevant systemic symptoms, an unexplained progressive neurologic disorder, or in a patient lacking risk factors for hemorrhagic stroke. Diagnosis is achieved after a high level of suspicion with conventional angiography and leptomeningeal biopsy.[53]
thrombocytopenia
Platelet counts less than 20,000/microliter are associated with spontaneous hemorrhagic stroke. Factors such as uremia and alcohol abuse are well known to cause dysfunctional platelet aggregation (thrombocytopathy) and act as the main mechanism for bleeding.
long sleep duration and poor sleep quality
Long sleep duration (≥9 hours/night), long midday napping (>90 minutes), and poor sleep quality are independently and jointly associated with higher risks of incident stroke.[54]
leukemia
Leukemia is associated with parenchymal hemorrhage and cerebral venous thrombosis independently of thrombocytopenia.
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