Hemorrhagic Stroke Clinical Presentation

7/27/2019 Hemorrhagic Stroke Clinical Presentation

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emedicine.medscape.com/article/1916662-clinical#showall

Hemorrhagic Stroke Clinical Presentation

Author: David S Liebeskind, MD; Chief Editor: Rick Kulkarni, MD more...

Updated: Mar 8, 2013

History

Obtaining an adequate history includes determining the onset and progression of symptoms, as well as assessing

for risk factors and possible causative events. Such risk factors include the following:

Previous transient ischemic attack (TIA) and stroke

Hypertension

Diabetes

Smoking

Arrhythmia and valvular diseaseIllicit drug use

Use of anticoagulants

Risk factors for thrombosis

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

Subarachnoid hemorrhage

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




emedicine.medscape.com/article/1916662-clinical#showall 2

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.[28] However, intracerebral hemorrhage may be clinically indistinguishable from ischemic stroke.

(Though stroke is less common in children, the clinical presentation is similar.)

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.[28]

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

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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.

Contributor Information and Disclosures

Author David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program,

University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging

Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke

Center

David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology,

American Heart Association, American Medical Association, American Society of Neuroimaging, American

Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Chief Editor Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance,

Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency

Medicine, University of Virginia School of Medicine

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


Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice

Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke

Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff,

Department of Neurology, Nashville Veterans Affairs Medical Center

http://www.saem.org/

http://www.acep.org/

http://www.aan.com/professionals/

http://www.aaem.org/


http://www.pbk.org/

http://www.amia.org/

http://www.ama-assn.org/



http://www.alphaomegaalpha.org/

http://www.americanheart.org/presenter.jhtml?identifier=1197

http://www.stroke.org/

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Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American

Academy of Neurology, American Heart Association, American Medical Association, American Neurological

Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and

Tennessee Medical Association


Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency

Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

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


Helmi L Lutsep, MD Professor, Department of Neurology, Oregon Health and Science University School of

Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and

American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel

membership; Concentric Medical Consulting fee Review panel membership

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


Jeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University of

California, Los Angeles, David Geffen School of Medicine

Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of

Neurology, American Heart Association, American Neurological Association, and National Stroke Association

Disclosure: University of California The University of California Regents receive funds for consulting services on

clinical trial design provided to Telecris, Ev3, and CoAxia. Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center

College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Hemorrhagic Stroke Clinical Presentation

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