Hemorrhagic Stroke Clinical Presentation

Updated: Apr 22, 2019
  • Author: David S Liebeskind, MD, FAAN, FAHA, FANA; Chief Editor: Andrew K Chang, MD, MS  more...
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Obtaining an adequate history includes determining the onset and progression of symptoms, as well as assessing for risk factors and possible causative events.

A history of trauma, even if minor, may be important, as extracranial arterial dissections can result in ischemic stroke.

Hemorrhagic versus ischemic stroke

Symptoms alone are not specific enough to distinguish ischemic from hemorrhagic stroke. However, generalized symptoms, including nausea, vomiting, and headache, as well as an altered level of consciousness, may indicate increased intracranial pressure and are more common with hemorrhagic strokes and large ischemic strokes.

Seizures are more common in hemorrhagic stroke than in the ischemic kind. Seizures occur in up to 28% of hemorrhagic strokes, generally at the onset of the intracerebral hemorrhage or within the first 24 hours.

Focal neurologic deficits

The neurologic deficits reflect the area of the brain typically involved, and stroke syndromes for specific vascular lesions have been described. Focal symptoms of stroke include the following:

  • Weakness or paresis that may affect a single extremity, one half of the body, or all 4 extremities

  • Facial droop

  • Monocular or binocular blindness

  • Blurred vision or visual field deficits

  • Dysarthria and trouble understanding speech

  • Vertigo or ataxia

  • Aphasia

Symptoms of subarachnoid hemorrhage may include the following:

  • Sudden onset of severe headache

  • Signs of meningismus with nuchal rigidity

  • Photophobia and pain with eye movements

  • Nausea and vomiting

  • Syncope - Prolonged or atypical

The most common clinical scoring systems for grading aneurysmal subarachnoid hemorrhage are the Hunt and Hess grading scheme and the World Federation of Neurosurgeons (WFNS) grading scheme, which incorporates the Glasgow Coma Scale. The Fisher Scale incorporates findings from noncontrast computed tomography (NCCT) scans.


Physical Examination

The assessment in patients with possible hemorrhagic stroke includes vital signs; a general physical examination that focuses on the head, heart, lungs, abdomen, and extremities; and a thorough but expeditious neurologic examination. [1]

Hypertension (particularly systolic blood pressure [BP] greater than 220 mm Hg) is commonly a prominent finding in hemorrhagic stroke. Higher initial BP is associated with early neurologic deterioration, as is fever. [1]

An acute onset of neurologic deficit, altered level of consciousness/mental status, or coma is more common with hemorrhagic stroke than with ischemic stroke. Often, this is caused by increased intracranial pressure. Meningismus may result from blood in the subarachnoid space.

Examination results can be quantified using various scoring systems. These include the Glasgow Coma Scale (GCS), the Intracerebral Hemorrhage Score (which incorporates the GCS; see Prognosis), and the National Institutes of Health Stroke Scale.

Focal neurologic deficits

The type of deficit depends upon the area of brain involved. If the dominant hemisphere (usually the left) is involved, a syndrome consisting of the following may result:

  • Right hemiparesis

  • Right hemisensory loss

  • Left gaze preference

  • Right visual field cut

  • Aphasia

  • Neglect (atypical)

If the nondominant (usually the right) hemisphere is involved, a syndrome consisting of the following may result:

  • Left hemiparesis

  • Left hemisensory loss

  • Right gaze preference

  • Left visual field cut

Nondominant hemisphere syndrome may also result in neglect when the patient has left-sided hemi-inattention and ignores the left side.

If the cerebellum is involved, the patient is at high risk for herniation and brainstem compression. Herniation may cause a rapid decrease in the level of consciousness and may result in apnea or death.

Specific brain sites and associated deficits involved in hemorrhagic stroke include the following:

  • Putamen - Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, aphasia, neglect, or apraxia

  • Thalamus - Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia, miosis, aphasia, or confusion

  • Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, abulia, aphasia, neglect, or apraxia

  • Caudate nucleus - Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion

  • Brainstem - Quadriparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular bobbing, miosis, or autonomic instability

  • Cerebellum – Ipsilateral ataxia, facial weakness, sensory loss; gaze paresis, skew deviation, miosis, or decreased level of consciousness

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, ranging from mild headache to neurologic devastation. At times, a cerebral hemorrhage may present as a new-onset seizure.