Hemorrhagic stroke: Difference between revisions

(Major expansion from stub: ICH score, BP targets (INTERACT2), anticoagulation reversal (PCC/idarucizumab/andexanet), spot sign, PATCH trial, cerebellar hemorrhage urgency, location-specific findings, references with PMIDs)
(Strip excess bold)
 
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==Background==
==Background==
*'''Spontaneous (nontraumatic) intracerebral hemorrhage''' accounts for '''10-15% of all strokes'''
*Spontaneous (nontraumatic) intracerebral hemorrhage accounts for 10-15% of all strokes
*'''Second most common cause of stroke''' after ischemic stroke
*Second most common cause of stroke after ischemic stroke
*'''30-day mortality: 40-50%''' — highest acute mortality of all stroke subtypes<ref>van Asch CJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time. ''Lancet Neurol''. 2010;9(2):167-176. PMID 20056489</ref>
*'''30-day mortality: 40-50%''' — highest acute mortality of all stroke subtypes<ref>van Asch CJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time. ''Lancet Neurol''. 2010;9(2):167-176. PMID 20056489</ref>
*Only '''20% of patients are functionally independent''' at 6 months
*Only 20% of patients are functionally independent at 6 months


===Etiology===
===Etiology===
*'''Hypertensive hemorrhage''' (most common — '''55-70%'''):
*Hypertensive hemorrhage (most common — 55-70%):
**Typically in basal ganglia (putamen), thalamus, pons, cerebellum
**Typically in basal ganglia (putamen), thalamus, pons, cerebellum
**Chronic hypertension → lipohyalinosis of small penetrating arteries → rupture
**Chronic hypertension → lipohyalinosis of small penetrating arteries → rupture
*'''Cerebral amyloid angiopathy''' (CAA):
*Cerebral amyloid angiopathy (CAA):
**Most common cause of '''lobar ICH in elderly'''
**Most common cause of lobar ICH in elderly
**Amyloid deposition in cortical/leptomeningeal vessel walls
**Amyloid deposition in cortical/leptomeningeal vessel walls
**Recurrent lobar hemorrhages
**Recurrent lobar hemorrhages
*'''Anticoagulation-related''': warfarin, DOACs ('''hematoma expansion''' more common)
*Anticoagulation-related: warfarin, DOACs (hematoma expansion more common)
*'''Vascular malformations''': AVM, cavernoma (consider in young patients without hypertension)
*Vascular malformations: AVM, cavernoma (consider in young patients without hypertension)
*'''Other''': cocaine/amphetamine use, hemorrhagic transformation of [[ischemic stroke]], tumors, coagulopathies, [[cerebral venous sinus thrombosis]]
*Other: cocaine/amphetamine use, hemorrhagic transformation of [[ischemic stroke]], tumors, coagulopathies, [[cerebral venous sinus thrombosis]]


==Clinical Features==
==Clinical Features==
*'''Sudden onset focal neurologic deficit''' with '''headache''' (worse than [[ischemic stroke]])
*Sudden onset focal neurologic deficit with headache (worse than [[ischemic stroke]])
*Nausea, vomiting (raised ICP)
*Nausea, vomiting (raised ICP)
*'''Progressive deterioration''' (hematoma expansion occurs in '''~30% within first 3 hours''')
*Progressive deterioration (hematoma expansion occurs in ~30% within first 3 hours)
*'''Cannot reliably distinguish from ischemic stroke clinically''' — '''neuroimaging is required'''
*Cannot reliably distinguish from ischemic stroke clinically — neuroimaging is required


===Location-Specific Findings===
===Location-Specific Findings===
*'''Putaminal''' (35-50%): contralateral hemiparesis, hemisensory loss, aphasia (dominant) or neglect
*Putaminal (35-50%): contralateral hemiparesis, hemisensory loss, aphasia (dominant) or neglect
*'''Thalamic''' (15-20%): contralateral hemisensory loss, upgaze palsy, small pupils
*Thalamic (15-20%): contralateral hemisensory loss, upgaze palsy, small pupils
*'''Cerebellar''' (5-10%): '''ataxia, vertigo, vomiting, headache''' → rapid deterioration from brainstem compression or hydrocephalus; '''SURGICAL EMERGENCY'''
*'''Cerebellar''' (5-10%): '''ataxia, vertigo, vomiting, headache''' → rapid deterioration from brainstem compression or hydrocephalus; '''SURGICAL EMERGENCY'''
*'''Pontine''' (5-10%): coma, quadriplegia, pinpoint pupils; '''high mortality'''
*Pontine (5-10%): coma, quadriplegia, pinpoint pupils; high mortality
*'''Lobar''' (20-30%): symptoms depend on lobe; seizures more common; consider amyloid angiopathy
*Lobar (20-30%): symptoms depend on lobe; seizures more common; consider amyloid angiopathy


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Imaging===
===Imaging===
*'''Non-contrast CT head''' (first-line — '''immediate'''): hyperdense (white) lesion
*Non-contrast CT head (first-line — immediate): hyperdense (white) lesion
**Detects hemorrhage with '''~100% sensitivity''' in first hours
**Detects hemorrhage with ~100% sensitivity in first hours
**Evaluate for: hematoma size, location, midline shift, intraventricular extension, hydrocephalus
**Evaluate for: hematoma size, location, midline shift, intraventricular extension, hydrocephalus
*'''CT angiography''' (CTA): identify '''spot sign''' (contrast extravasation = active bleeding, predicts hematoma expansion)<ref>Demchuk AM, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT). ''Lancet Neurol''. 2012;11(4):307-314. PMID 22405630</ref>
*CT angiography (CTA): identify spot sign (contrast extravasation = active bleeding, predicts hematoma expansion)<ref>Demchuk AM, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT). ''Lancet Neurol''. 2012;11(4):307-314. PMID 22405630</ref>
**Also evaluates for underlying vascular malformation
**Also evaluates for underlying vascular malformation
*'''MRI/MRA''': after stabilization to evaluate for underlying cause (especially if atypical location or age <50)
*MRI/MRA: after stabilization to evaluate for underlying cause (especially if atypical location or age <50)


===Labs===
===Labs===
*'''Coagulation studies''': PT/INR (warfarin), PTT (heparin), thrombin time (dabigatran)
*Coagulation studies: PT/INR (warfarin), PTT (heparin), thrombin time (dabigatran)
*CBC with platelets
*CBC with platelets
*BMP, glucose
*BMP, glucose
*Type and screen
*Type and screen
*'''Toxicology screen''' if cocaine/amphetamine use suspected
*Toxicology screen if cocaine/amphetamine use suspected


===ICH Score (Prognosis)===
===ICH Score (Prognosis)===
*'''GCS 3-4''' (+2), '''5-12''' (+1), '''13-15''' (0)
*GCS 3-4 (+2), 5-12 (+1), 13-15 (0)
*'''ICH volume ≥30 cm3''' (+1)
*ICH volume ≥30 cm3 (+1)
*'''Intraventricular hemorrhage''' (+1)
*Intraventricular hemorrhage (+1)
*'''Infratentorial origin''' (+1)
*Infratentorial origin (+1)
*'''Age ≥80''' (+1)
*Age ≥80 (+1)
*Score 0: ~0% 30-day mortality; Score 5: ~100% mortality
*Score 0: ~0% 30-day mortality; Score 5: ~100% mortality
*'''Should NOT be used to limit care''' (self-fulfilling prophecy concern)
*Should NOT be used to limit care (self-fulfilling prophecy concern)


==Management==
==Management==
===Blood Pressure===
===Blood Pressure===
*'''AHA/ASA Guidelines'''<ref>Greenberg SM, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage. ''Stroke''. 2022;53(7):e282-e361. PMID 35579034</ref>:
*AHA/ASA Guidelines<ref>Greenberg SM, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage. ''Stroke''. 2022;53(7):e282-e361. PMID 35579034</ref>:
**If SBP '''150-220 mmHg''': '''target SBP 140 mmHg''' is safe and may improve outcomes (INTERACT2 trial)
**If SBP 150-220 mmHg: target SBP 140 mmHg is safe and may improve outcomes (INTERACT2 trial)
**If SBP '''>220 mmHg''': aggressive reduction with continuous IV infusion and frequent monitoring (target 140-160)
**If SBP >220 mmHg: aggressive reduction with continuous IV infusion and frequent monitoring (target 140-160)
**'''Nicardipine''' infusion (5-15 mg/hr) or '''clevidipine''' preferred
**Nicardipine infusion (5-15 mg/hr) or clevidipine preferred
**Labetalol IV as alternative
**Labetalol IV as alternative
**'''Avoid SBP <120 mmHg''' (risk of renal injury)
**Avoid SBP <120 mmHg (risk of renal injury)


===Anticoagulation Reversal===
===Anticoagulation Reversal===
*'''Warfarin''' (elevated INR):
*Warfarin (elevated INR):
**'''4-factor PCC (Kcentra) 25-50 units/kg IV''' (preferred — rapid, complete reversal)
**4-factor PCC (Kcentra) 25-50 units/kg IV (preferred — rapid, complete reversal)
**'''+ Vitamin K 10 mg IV''' (takes hours but provides sustained reversal)
**+ Vitamin K 10 mg IV (takes hours but provides sustained reversal)
**'''FFP is second-line''' (requires thawing, large volume, incomplete reversal)
**FFP is second-line (requires thawing, large volume, incomplete reversal)
*'''Dabigatran''': '''idarucizumab (Praxbind) 5g IV''' (immediate reversal)
*Dabigatran: idarucizumab (Praxbind) 5g IV (immediate reversal)
*'''Rivaroxaban/Apixaban''': '''andexanet alfa (Andexxa)''' if available; otherwise '''4-factor PCC 50 units/kg'''
*Rivaroxaban/Apixaban: andexanet alfa (Andexxa) if available; otherwise 4-factor PCC 50 units/kg
*'''Heparin''': protamine sulfate
*Heparin: protamine sulfate
*'''Antiplatelet agents''': '''platelet transfusion is NOT recommended''' (PATCH trial showed harm)
*Antiplatelet agents: platelet transfusion is NOT recommended (PATCH trial showed harm)


===Seizure Management===
===Seizure Management===
*Treat clinical seizures with [[benzodiazepines]], then AEDs (levetiracetam preferred)
*Treat clinical seizures with [[benzodiazepines]], then AEDs (levetiracetam preferred)
*'''Prophylactic AEDs are NOT routinely recommended'''
*Prophylactic AEDs are NOT routinely recommended
*Consider continuous EEG for patients with AMS out of proportion to hemorrhage
*Consider continuous EEG for patients with AMS out of proportion to hemorrhage


===Cerebellar Hemorrhage===
===Cerebellar Hemorrhage===
*'''Neurosurgical EMERGENCY'''
*'''Neurosurgical EMERGENCY'''
*'''Surgical evacuation''' for hematoma >3 cm OR evidence of brainstem compression OR hydrocephalus
*Surgical evacuation for hematoma >3 cm OR evidence of brainstem compression OR hydrocephalus
*'''EVD''' (external ventricular drain) for obstructive hydrocephalus
*EVD (external ventricular drain) for obstructive hydrocephalus
*'''These patients can deteriorate rapidly to death without surgery'''
*'''These patients can deteriorate rapidly to death without surgery'''


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==Disposition==
==Disposition==
*'''All patients with ICH require ICU admission''' in a stroke center/neurosurgical center
*All patients with ICH require ICU admission in a stroke center/neurosurgical center
*'''Neurosurgery consultation''' for: cerebellar hemorrhage, large hematoma with mass effect, hydrocephalus, young patient with suspected vascular malformation
*Neurosurgery consultation for: cerebellar hemorrhage, large hematoma with mass effect, hydrocephalus, young patient with suspected vascular malformation
*'''Goals of care discussion''' early — but '''avoid early withdrawal of care''' (ICH score is imperfect)
*Goals of care discussion early — but avoid early withdrawal of care (ICH score is imperfect)
*'''Transfer to stroke center''' if local neurosurgical capability unavailable
*Transfer to stroke center if local neurosurgical capability unavailable


==See Also==
==See Also==

Latest revision as of 09:26, 22 March 2026

Background

  • Spontaneous (nontraumatic) intracerebral hemorrhage accounts for 10-15% of all strokes
  • Second most common cause of stroke after ischemic stroke
  • 30-day mortality: 40-50% — highest acute mortality of all stroke subtypes[1]
  • Only 20% of patients are functionally independent at 6 months

Etiology

  • Hypertensive hemorrhage (most common — 55-70%):
    • Typically in basal ganglia (putamen), thalamus, pons, cerebellum
    • Chronic hypertension → lipohyalinosis of small penetrating arteries → rupture
  • Cerebral amyloid angiopathy (CAA):
    • Most common cause of lobar ICH in elderly
    • Amyloid deposition in cortical/leptomeningeal vessel walls
    • Recurrent lobar hemorrhages
  • Anticoagulation-related: warfarin, DOACs (hematoma expansion more common)
  • Vascular malformations: AVM, cavernoma (consider in young patients without hypertension)
  • Other: cocaine/amphetamine use, hemorrhagic transformation of ischemic stroke, tumors, coagulopathies, cerebral venous sinus thrombosis

Clinical Features

  • Sudden onset focal neurologic deficit with headache (worse than ischemic stroke)
  • Nausea, vomiting (raised ICP)
  • Progressive deterioration (hematoma expansion occurs in ~30% within first 3 hours)
  • Cannot reliably distinguish from ischemic stroke clinically — neuroimaging is required

Location-Specific Findings

  • Putaminal (35-50%): contralateral hemiparesis, hemisensory loss, aphasia (dominant) or neglect
  • Thalamic (15-20%): contralateral hemisensory loss, upgaze palsy, small pupils
  • Cerebellar (5-10%): ataxia, vertigo, vomiting, headache → rapid deterioration from brainstem compression or hydrocephalus; SURGICAL EMERGENCY
  • Pontine (5-10%): coma, quadriplegia, pinpoint pupils; high mortality
  • Lobar (20-30%): symptoms depend on lobe; seizures more common; consider amyloid angiopathy

Differential Diagnosis

Evaluation

Imaging

  • Non-contrast CT head (first-line — immediate): hyperdense (white) lesion
    • Detects hemorrhage with ~100% sensitivity in first hours
    • Evaluate for: hematoma size, location, midline shift, intraventricular extension, hydrocephalus
  • CT angiography (CTA): identify spot sign (contrast extravasation = active bleeding, predicts hematoma expansion)[2]
    • Also evaluates for underlying vascular malformation
  • MRI/MRA: after stabilization to evaluate for underlying cause (especially if atypical location or age <50)

Labs

  • Coagulation studies: PT/INR (warfarin), PTT (heparin), thrombin time (dabigatran)
  • CBC with platelets
  • BMP, glucose
  • Type and screen
  • Toxicology screen if cocaine/amphetamine use suspected

ICH Score (Prognosis)

  • GCS 3-4 (+2), 5-12 (+1), 13-15 (0)
  • ICH volume ≥30 cm3 (+1)
  • Intraventricular hemorrhage (+1)
  • Infratentorial origin (+1)
  • Age ≥80 (+1)
  • Score 0: ~0% 30-day mortality; Score 5: ~100% mortality
  • Should NOT be used to limit care (self-fulfilling prophecy concern)

Management

Blood Pressure

  • AHA/ASA Guidelines[3]:
    • If SBP 150-220 mmHg: target SBP 140 mmHg is safe and may improve outcomes (INTERACT2 trial)
    • If SBP >220 mmHg: aggressive reduction with continuous IV infusion and frequent monitoring (target 140-160)
    • Nicardipine infusion (5-15 mg/hr) or clevidipine preferred
    • Labetalol IV as alternative
    • Avoid SBP <120 mmHg (risk of renal injury)

Anticoagulation Reversal

  • Warfarin (elevated INR):
    • 4-factor PCC (Kcentra) 25-50 units/kg IV (preferred — rapid, complete reversal)
    • + Vitamin K 10 mg IV (takes hours but provides sustained reversal)
    • FFP is second-line (requires thawing, large volume, incomplete reversal)
  • Dabigatran: idarucizumab (Praxbind) 5g IV (immediate reversal)
  • Rivaroxaban/Apixaban: andexanet alfa (Andexxa) if available; otherwise 4-factor PCC 50 units/kg
  • Heparin: protamine sulfate
  • Antiplatelet agents: platelet transfusion is NOT recommended (PATCH trial showed harm)

Seizure Management

  • Treat clinical seizures with benzodiazepines, then AEDs (levetiracetam preferred)
  • Prophylactic AEDs are NOT routinely recommended
  • Consider continuous EEG for patients with AMS out of proportion to hemorrhage

Cerebellar Hemorrhage

  • Neurosurgical EMERGENCY
  • Surgical evacuation for hematoma >3 cm OR evidence of brainstem compression OR hydrocephalus
  • EVD (external ventricular drain) for obstructive hydrocephalus
  • These patients can deteriorate rapidly to death without surgery

Increased ICP Management

  • Elevate HOB to 30°
  • EVD for hydrocephalus or IVH with acute hydrocephalus
  • Osmotic therapy: mannitol or hypertonic saline
  • Consider surgical hematoma evacuation (benefit primarily for superficial lobar hemorrhages)

Disposition

  • All patients with ICH require ICU admission in a stroke center/neurosurgical center
  • Neurosurgery consultation for: cerebellar hemorrhage, large hematoma with mass effect, hydrocephalus, young patient with suspected vascular malformation
  • Goals of care discussion early — but avoid early withdrawal of care (ICH score is imperfect)
  • Transfer to stroke center if local neurosurgical capability unavailable

See Also

References

  1. ↑ van Asch CJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time. Lancet Neurol. 2010;9(2):167-176. PMID 20056489
  2. ↑ Demchuk AM, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT). Lancet Neurol. 2012;11(4):307-314. PMID 22405630
  3. ↑ Greenberg SM, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage. Stroke. 2022;53(7):e282-e361. PMID 35579034
  • Hemphill JC 3rd, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: AHA/ASA guideline. Stroke. 2015;46(7):2032-2060. PMID 26022637
  • Anderson CS, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage (INTERACT2). N Engl J Med. 2013;368(25):2355-2365. PMID 23713578
  • Baharoglu MI, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH). Lancet. 2016;387(10038):2605-2613. PMID 27178479
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