eMedicine Specialties > Emergency Medicine > Neurology

Stroke, Hemorrhagic

Author: Denise Nassisi, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Contributor Information and Disclosures

Updated: Mar 9, 2010

Introduction

Background

The terms intracerebral hemorrhage (ICH) and hemorrhagic stroke are used interchangeably in this discussion and are regarded as a separate entity from hemorrhagic transformation of ischemic stroke. Intracerebral hemorrhage accounts for 10-15% of all strokes and is associated with higher mortality rates than cerebral infarctions.1 Patients with hemorrhagic stroke present with similar focal neurologic deficits but tend to be more ill than patients with ischemic stroke. Patients with intracerebral bleeds are more likely to have headache, altered mental status, seizures, nausea and vomiting, and/or marked hypertension; however, none of these findings reliably distinguishes between hemorrhagic stroke and ischemic stroke.

An intracerebral hemorrhage is shown in the CT below.

Large intracerebral hemorrhage with midline shift.

Large intracerebral hemorrhage with midline shift.

[ CLOSE WINDOW ]
Large intracerebral hemorrhage with midline shift.

Large intracerebral hemorrhage with midline shift.


Pathophysiology

In intracerebral hemorrhage (ICH), bleeding occurs directly into the brain parenchyma. The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension. Other mechanisms include bleeding diatheses, iatrogenic anticoagulation, cerebral amyloidosis, and cocaine abuse. Intracerebral hemorrhage has a predilection for certain sites in the brain, including the thalamus, putamen, cerebellum, and brainstem. In addition to the area of the brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by the mass effect of the hematoma. A general increase in intracranial pressure may occur.

Frequency

United States

Intracerebral hemorrhage accounts for 10-15% of all strokes.1 Recent reports indicate an incidence exceeding 500,000 new strokes of all types per year.

Mortality/Morbidity

  • Stroke is a leading killer and disabler. Combining all types of stroke, it is the third leading cause of death and the first leading cause of disability.
  • Morbidity is more severe and mortality rates are higher for hemorrhagic stroke than for ischemic stroke. Only 20% of patients regain functional independence.1
  • The 30-day mortality rate for hemorrhagic stroke is 40-80%. Approximately 50% of all deaths occur within the first 48 hours.1
    • A recent study of 474 ICH patients found that for those younger than 75 years of age, male sex predicted a poor outcome. Within 28 days, 20% of women and 23% of men died (P=0.38); in those 75 years or older, the corresponding figures were 26% and 41%, respectively (P=0.02). Other independent predictors of death were high age, central and brainstem hemorrhage location, intraventricular hemorrhage, increased volume, and decreased level of consciousness.2

Race

African Americans have a higher incidence of hemorrhagic and ischemic strokes than other races in the United States. The incidence of hemorrhagic stroke in the Japanese population is increased.

Age

The risk of stroke increases with age.

Clinical

History

  • Patients' symptoms vary depending on the area of the brain affected and the extent of the bleeding.
  • Hemorrhagic strokes are more likely to exhibit symptoms of increased intracranial pressure than other types of stroke.
    • Headache, often severe and sudden onset
    • Nausea and/or vomiting
  • Seizures are more common in hemorrhagic stroke than in ischemic stroke. They occur in up to 28% of hemorrhagic strokes and generally occur at the onset of the intracerebral hemorrhage (ICH) or within the first 24 hours.

Physical

  • Intracerebral hemorrhage (ICH) may be clinically indistinguishable from ischemic stroke.
  • Hypertension is commonly a prominent finding.
  • An altered level of consciousness or coma is more common with hemorrhagic stroke than with ischemic stroke. Often, this is due to an increase in intracranial pressure.
  • Meningismus may result from blood in the ventricles.
  • Focal neurologic deficits
    • The type of deficit depends upon the area of brain involved.
    • If the dominant hemisphere (usually left) is involved, a syndrome consisting of right hemiparesis, right hemisensory loss, left gaze preference, right visual field cut, and aphasia may result.
    • If the nondominant (usually right) hemisphere is involved, a syndrome of left hemiparesis, left hemisensory loss, right gaze preference, and left visual field cut may result. Nondominant hemisphere syndrome may also result in neglect when the patient has a left-sided hemi-inattention and ignores the left side.
    • If the cerebellum is involved, the patient is at high risk of herniation and brainstem compression. Herniation may cause a rapid decrease in the level of consciousness, apnea, and death.
    • Other signs of cerebellar or brainstem involvement include the following:
      • Gait or limb ataxia
      • Vertigo or tinnitus
      • Nausea and vomiting
      • Hemiparesis or quadriparesis
      • Hemisensory loss or sensory loss of all 4 limbs
      • Eye movement abnormalities resulting in diplopia or nystagmus
      • Oropharyngeal weakness or dysphagia
      • Crossed signs (ipsilateral face and contralateral body)
    • Many other stroke syndromes are associated with intracerebral hemorrhage (ICH), ranging from mild headache to neurologic devastation. At times, a cerebral hemorrhage may present as a new-onset seizure.

Causes

  • Hypertension (up to 60% of cases)
  • Advanced age (risk factor)
  • Cerebral amyloidosis (affects people who are elderly and may cause up to 10% of intracerebral hemorrhages [ICHs])
  • Coagulopathies (eg, due to underlying systemic disorders such as bleeding diathesis or liver disease)
  • Anticoagulant therapy
  • Thrombolytic therapy for acute myocardial infarction (MI) and acute ischemic stroke (can cause iatrogenic hemorrhagic stroke)
  • Abuse of cocaine and other sympathomimetic drugs
  • Arteriovenous malformation
  • Intracranial aneurysm
  • Vasculitis
  • Intracranial neoplasm
  • History of prior stroke (risk factor)

More on Stroke, Hemorrhagic

Overview: Stroke, Hemorrhagic
Differential Diagnoses & Workup: Stroke, Hemorrhagic
Treatment & Medication: Stroke, Hemorrhagic
Follow-up: Stroke, Hemorrhagic
Multimedia: Stroke, Hemorrhagic
References
[ CLOSE WINDOW ]

References

  1. [Guideline] Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation. Oct 16 2007;116(16):e391-413. [Medline].

  2. Zia E, Engström G, Svensson PJ, Norrving B, Pessah-Rasmussen H. Three-year survival and stroke recurrence rates in patients with primary intracerebral hemorrhage. Stroke. Nov 2009;40(11):3567-73. [Medline].

  3. Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G. Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia. Oct 2002;43(10):1175-80. [Medline].

  4. Vespa PM, O'Phelan K, Shah M, et al. Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology. May 13 2003;60(9):1441-6. [Medline].

  5. Misra UK, Kalita J, Ranjan P, Mandal SK. Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci. Jul 15 2005;234(1-2):41-5. [Medline].

  6. Mayer SA, Brun NC, Begtrup K, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. May 15 2008;358(20):2127-37. [Medline].

  7. [Best Evidence] Diringer MN, Skolnick BE, Mayer SA, Steiner T, Davis SM, Brun NC, et al. Thromboembolic events with recombinant activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Stroke. Jan 2010;41(1):48-53. [Medline].

  8. Lankiewicz MW, Hays J, Friedman KD, Tinkoff G, Blatt PM. Urgent reversal of warfarin with prothrombin complex concentrate. J Thromb Haemost. May 2006;4(5):967-70. [Medline].

  9. Huttner HB, Schellinger PD, Hartmann M, et al. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke. Jun 2006;37(6):1465-70. [Medline].

  10. [Best Evidence] Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. Jan 29-Feb 4 2005;365(9457):387-97. [Medline].

  11. Aguilar MI, Hart RG, Kase CS, et al. Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion. Mayo Clin Proc. Jan 2007;82(1):82-92. [Medline].

  12. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sep 2004;126(3 Suppl):204S-233S. [Medline].

  13. [Guideline] Broderick JP, Adams HP Jr, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. Apr 1999;30(4):905-15. [Medline].

  14. Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. Jan 1997;28(1):1-5. [Medline].

  15. Brott T, Thalinger K, Hertzberg V. Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke. Nov-Dec 1986;17(6):1078-83. [Medline].

  16. Brown DL, Morgenstern LB. Stopping the bleeding in intracerebral hemorrhage. N Engl J Med. Feb 24 2005;352(8):828-30. [Medline].

  17. Cassels C. FAST Trial Shows No Benefit of Factor VII in Treatment of ICH. May 2007. Medscape from WebMD. Available at http://www.medscape.com/viewarticle/557558.

  18. Davis SM, Broderick J, Hennerici M, et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. Apr 25 2006;66(8):1175-81. [Medline].

  19. Donahue RP, Abbott RD, Reed DM, Yano K. Alcohol and hemorrhagic stroke. The Honolulu Heart Program. JAMA. May 2 1986;255(17):2311-4. [Medline].

  20. Donnan GA, Davis SM. Surgery for intracerebral hemorrhage: an evidence-poor zone. Stroke. Jun 2003;34(6):1569-70. [Medline].

  21. Fiebach JB, Schellinger PD, Gass A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke. Feb 2004;35(2):502-6. [Medline].

  22. Flibotte JJ, Hagan N, O'Donnell J, Greenberg SM, Rosand J. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology. Sep 28 2004;63(6):1059-64. [Medline].

  23. Goldstein JN, Rosand J, Schwamm LH. Warfarin reversal in anticoagulant-associated intracerebral hemorrhage. Neurocrit Care. 2008;9(2):277-83. [Medline].

  24. Goldstein JN, Thomas SH, Frontiero V, et a. Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke. Jan 2006;37(1):151-5. [Medline].

  25. Hankey GJ. Evacuation of intracerebral hematoma is likely to be beneficial--against. Stroke. Jun 2003;34(6):1568-9. [Medline].

  26. Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. Apr 2001;32(4):891-7. [Medline].

  27. Kaneko M, Tanaka K, Shimada T, Sato K, Uemura K. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg. Jun 1983;58(6):838-42. [Medline].

  28. Kanno T, Sano H, Shinomiya Y, et al. Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg. Dec 1984;61(6):1091-9. [Medline].

  29. Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. Oct 20 2004;292(15):1823-30. [Medline].

  30. Kopitnik TA Jr, Kaufman HH. The future. Prospects of innovative treatment of intracerebral hemorrhage. Neurosurg Clin N Am. Jul 1992;3(3):703-7. [Medline].

  31. Lee SB, Manno EM, Layton KF, Wijdicks EF. Progression of warfarin-associated intracerebral hemorrhage after INR normalization with FFP. Neurology. Oct 10 2006;67(7):1272-4. [Medline].

  32. Leira R, Davalos A, Silva Y, Gil-Peralta A, Tejada J, Garcia M. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology. Aug 10 2004;63(3):461-7. [Medline].

  33. Mader TJ, Mandel A. A new clinical scoring system fails to differentiate hemorrhagic from ischemic stroke when used in the acute care setting. J Emerg Med. Jan-Feb 1998;16(1):9-13. [Medline].

  34. Makris M, Greaves M, Phillips WS, Kitchen S, Rosendaal FR, Preston EF. Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thromb Haemost. Mar 1997;77(3):477-80. [Medline].

  35. Mayer SA. Recombinant activated factor VII for acute intracerebral hemorrhage. Stroke. Feb 2007;38(2 Suppl):763-7. [Medline].

  36. [Best Evidence] Mayer SA, Brun NC, Begtrup K, et al. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. Feb 24 2005;352(8):777-85. [Medline].

  37. Mayer SA, Davis SM, Skolnick BE, et al. Can a subset of intracerebral hemorrhage patients benefit from hemostatic therapy with recombinant activated factor VII?. Stroke. Mar 2009;40(3):833-40. [Medline].

  38. Melamed N, Satya-Murti S. Cerebellar hemorrhage. A review and reappraisal of benign cases. Arch Neurol. Apr 1984;41(4):425-8. [Medline].

  39. National Stroke Association Consensus Group. Stroke: the first hours-emergency evaluation and treatment. Stroke Clinical Updates. 1997;5-14.

  40. NINDS ICH Workshop Participants. Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke workshop. Stroke. Mar 2005;36(3):e23-41. [Medline].

  41. Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke. Jun 2004;35(6):1364-7. [Medline].

  42. Patel MR, Edelman RR, Warach S. Detection of hyperacute primary intraparenchymal hemorrhage by magnetic resonance imaging. Stroke. Dec 1996;27(12):2321-4. [Medline].

  43. Qureshi AI, Harris-Lane P, Kirmani JF, et al. Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines. Crit Care Med. Jul 2006;34(7):1975-80. [Medline].

  44. Qureshi AI, Mohammad YM, Yahia AM, et al. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med. Jan-Feb 2005;20(1):34-42. [Medline].

  45. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. May 10 2001;344(19):1450-60. [Medline].

  46. Raj G, Kumar R, McKinney WP. Time course of reversal of anticoagulant effect of warfarin by intravenous and subcutaneous phytonadione. Arch Intern Med. Dec 13-27 1999;159(22):2721-4. [Medline].

  47. Schulman S. Clinical practice. Care of patients receiving long-term anticoagulant therapy. N Engl J Med. Aug 14 2003;349(7):675-83. [Medline].

  48. Sjoblom L, Hardemark HG, Lindgren A, et al. Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study. Stroke. Nov 2001;32(11):2567-74. [Medline].

  49. [Guideline] Steiner T, Kaste M, Forsting M, et al. Recommendations for the management of intracranial haemorrhage - part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis. 2006;22(4):294-316. [Medline].

  50. Steiner T, Rosand J, Diringer M. Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions. Stroke. Jan 2006;37(1):256-62. [Medline].

  51. Toyoda K, Okada Y, Minematsu K, Kamouchi M, Fujimoto S, Ibayashi S. Antiplatelet therapy contributes to acute deterioration of intracerebral hemorrhage. Neurology. Oct 11 2005;65(7):1000-4. [Medline].

  52. Vinters HB, Gilber JJ. Amyloid angiopathy: its incidence and complications in the aging brain. Stroke. 1981;12:118-120.

  53. Zweifler RM. Management of acute stroke. South Med J. Apr 2003;96(4):380-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hemorrhagic stroke, stroke hemorrhagic, stroke symptoms, stroke signs, stroke treatment, stroke management, intracerebral hemorrhage, ICH, intracerebral bleeds, cerebrovascular accident, CVA, stroke syndrome, antithrombotic therapy, thrombolytic therapy, stroke prognosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Denise Nassisi, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Denise Nassisi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.