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.
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Reference article
This is a summary article; read more in our article on intracerebral hemorrhage.
Summary
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epidemiology
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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
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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
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pathophysiology
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most commonly caused by a spontaneous rupture of small blood vessels within the brain, causing an intracerebral hemorrhage 1
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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
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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
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investigation
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non-contrast CT head in the first instance
shows intracerebral hemorrhage and associated complications 2
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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
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contrast-enhanced CT
some centers use this to identify any underlying tumors 2
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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
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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
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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
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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?
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radiographic features
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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
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angiography (CTA/MRA/DSA)
may assist with determining whether there is likelihood of hematoma expansion 2
may identify underlying vascular malformations 2
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contrast-enhanced CT
some centers use this to identify any underlying tumors, although MRI is a better imaging modality for this
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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
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