Hemorrhagic Stroke Workup

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emedicine.medscape.com/article/1916662-workup

Hemorrhagic Stroke Workup

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

Updated: Mar 8, 2013

Approach Considerations

Laboratory tests should include a complete blood count, a metabolic panel, andparticularly in patients takinganticoagulantscoagulation studies (ie, prothrombin time or international normalized ratio [INR] and an

activated partial thromboplastin time).[28]

Brain imaging is a crucial step in the evaluation of suspected hemorrhagic stroke and must be obtained on an

emergent basis. Brain imaging aids diagnosing hemorrhage, and it may identify complications such as

intraventricular hemorrhage, brain edema, or hydrocephalus. Either noncontrast computed tomography (NCCT)

scanning or magnetic resonance imaging (MRI) is the modality of choice.

Computed tomography (CT)-scan studies can also be performed in patients who are unable to tolerate a

magnetic resonance examination or who have contraindications to MRI, including pacemakers, aneurysm

clips, or other ferromagnetic materials in their bodies. Additionally, CT-scan examination is more easily

accessible for patients who require special equipment for life support. See the image below.

Noncontrast computed tomography scan of the brain (left) demonstrates an acute hemorrhage in the left gangliocapsular region,

w ith surrounding w hite matter hypodensity consistent w ith vasogenic edema. T2-w eighted axial magnetic resonance imaging scan

(middle image) again demonstrates the hemorrhage, w ith surrounding high-signal edema. The coronal gradient-echo image (right)

demonstrates susceptibility related to the hematoma, w ith markedly low signal adjacent the left caudate head. Gradient-echo images

are highly sensitive for blood products.

CT angiography and contrast-enhanced CT scanning may be considered for helping identify patients at risk for

hematoma expansion. Extravasation of contrast within the hematoma indicates high risk.

When clinical or radiologic findings suggest an underlying structural lesion, useful techniques include CT

angiography, CT venography, contrast-enhanced CT scanning, contrast-enhanced MRI, magnetic resonance

angiography (MRA), or magnetic resonance venography.[28]

Conventional angiography is the gold standard in evaluating for cerebrovascular disease and for providing less-

invasive endovascular interventions. This modality can be performed to clarify equivocal findings or to confirm

and treat disease seen on MRA, CTA, transcranial Doppler, or neck ultrasonograms. However, Zhu et al found

that in patients with spontaneous intracranial hemorrhage, angiographic yield was significantly lower in patients

older than 45 years and those who had preexisting hypertension. [29]

Although the traditional approach to excluding underlying vascular abnormalities in patients with spontaneous

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emedicine.medscape.com/article/1916662-workup 2

intracerebral hemorrhage is to use digital subtraction angiography (DSA) in the acute and subacute phases,

Wong et al found that MRA was able to detect most structural vascular abnormalities in the subacute phase in

most patients. Consequently, they recommend MRA as the screening test.

Contributor Information and DisclosuresAuthor

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 ofEmergency 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

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
http://www.saem.org/http://www.acep.org/http://www.aaem.org/http://www.alphaomegaalpha.org/http://www.medwire.org/http://www.pbk.org/http://www.stroke.org/http://www.asnr.com/http://www.aneuroa.org/http://www.ama-assn.org/http://www.americanheart.org/presenter.jhtml?identifier=1200000http://www.aan.com/professionals/http://www.alphaomegaalpha.org/http://www.saem.org/http://www.acep.org/http://www.aan.com/professionals/http://www.aaem.org/http://www.saem.org/http://www.pbk.org/http://www.amia.org/http://www.ama-assn.org/http://www.acep.org/http://www.aaem.org/http://www.alphaomegaalpha.org/http://www.americanheart.org/presenter.jhtml?identifier=1197http://www.stroke.org/http://www.asnr.org/http://www.asnweb.org/http://www.ama-assn.org/http://www.americanheart.org/presenter.jhtml?identifier=1200000http://www.aan.com/professionals/


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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 ofEmergency 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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