QuestionSBA
QuestionChoice
Cerebral amyloid angiopathy is the most common cause of lobar intracerebral haemorrhage in older adults. A thalamic stroke is more likely to be due to hypertensive vasculopathy
32365
c
Cerebral amyloid angiopathy
QuestionChoice
Trauma can lead to intracerebral haemorrhage; however, the absence of any external injuries on examination would go against this as the most likely cause
32366
d
Trauma
QuestionChoice
Vasculitis can cause stroke, but it is rare and most commonly seen in younger patients
32367
e
Vasculitis
QuestionChoice
Hypertension is the most common cause of spontaneous intracerebral haemorrhage. The pathogenesis is due to hypertension leading to the formation, and subsequent rupture, of Charcot-Bouchard aneurysms in the small penetrating blood vessels of the brain
32363
a
Hypertensive vasculopathy
QuestionChoice
AVM are an important but less common cause of intracerebral haemorrhage
32364
b
Arteriovenous malformation (AVM)
QuestionComment
B***, you test me
15972
User
subscriber
George
Concept
Chapter
# Summary

A haemorrhagic stroke results from the rupture of a cerebral vessel, leading to intracranial bleeding. Signs include severe headache, altered consciousness, meningism and focal neurological deficits. CT Head is the first-line investigation to quickly identify haemorrhage. MRI scans may be used to provide more detailed images and help identify an underlying cause. Management should be in a specialist unit (either a stroke unit or neurocritical care) with a focus on optimal blood pressure control, particularly in the early phase. Any anticoagulation treatment should be reversed and blood pressure control is key to optimising outcomes. In select cases, surgical decompression may be considered.

# Definition

Haemorrhagic stroke is a cerebrovascular event that occurs when there is bleeding into the brain parenchyma, ventricles or subarachnoid space. This may lead to haematoma formation with raised intracranial pressure, as well as neuronal damage.
 
# Epidemiology

- Haemorrhagic strokes contribute to 10% to 20% of strokes annually
- Incidence is around 12 to 15% per 1,000,000 per year 
- Incidence is more common in men and increases with age
- The case fatality rate is 25 to 30% 


# Aetiology
 
Risk factors for haemorrhagic stroke include:

 - Older age 
 - Male sex
 - Family history of haemorrhagic stroke
 - Haemophilia and other bleeding disorders
 - Cerebral amyloid angiopathy (CAA)
 - **Hypertension**
 - Anticoagulation therapy
 - Recreational drugs such as cocaine and amphetamines
 - Arteriovenous malformations (particularly in younger patients)

# Signs and Symptoms
 
- Severe headache
- Altered consciousness, ranging from drowsiness to coma
- Vomiting
- Nuchal rigidity
- Focal neurologic signs e.g. weakness, visual loss, sensory changes
- Aphasia
- Seizures
- Hypertension
 
# Differential Diagnosis
 
- **Ischaemic stroke:** Both present with sudden onset neurological defict. Headache is more likely in haemorrhagic stroke. CT is required to rule out haemorrhage before treating for ischaemic stroke
- **Space-occupying lesion:** e.g. a brain tumour can cause similar symptoms of headache, focal neurological deficits and altered consciousness however these are usually chronic and progressive rather than acute in onset
- **Meningitis:** also causes headache, meningism and altered mental status; more likely to have features of infection e.g. fevers, tachycardia 
- **Hypertensive encephalopathy:** also presents with acute onset of headache, confusion, visual disturbances and seizures associated with hypertension; may have other complications e.g. myocardial ischaemia, renal dysfunction, differentiated from stroke with a CT head
 
# Investigations
 
**Bedside tests:**

- **Capillary blood glucose** as maintaining normoglycaemia improves outcomes 
- **Blood pressure** is important to monitor as a potential cause and during the management blood pressure control is key
- **ECG** as there may be cardiac complications of haemorrhagic stroke e.g. arrhythmias
- **Urine toxicology screen** if illicit drug use is suspected

**Blood tests:**

- **FBC** and **CRP** for inflammatory markers 
- **Coagulation screen** to identify any bleeding diathesis
- **U&Es** to identify any renal impairment that may be associated with hypertension
- **LFTs** as a baseline

**Imaging**

- **Non Contrast CT head** is the key investigation to identify haemorrhagic stroke
- **MRI head** may be done in some cases to give more detail, identify an underlying cause and plan treatment
- **MR angiography** or **digital subtraction angiography** can help identify any vascular abnormalities that may have caused the haemorrhage

# Management
 
- Emergency management of a haemorrhagic stroke should involve urgently contacting the stroke team +/- critical care (for example in cases with reduced consciousness)
- Urgent neurosurgical referral may be required e.g. for haematoma evacuation
- Reverse any anticoagulation treatment or clotting disorders
- Rapid blood pressure lowering should be initiated in patients with a systolic blood pressure of 150-220 mmHg 
    - This is usually with IV antihypertensives such as GTN or labetalol
    - Aim for a systolic blood pressure of below 140 mmHg, but without a fall of > 60 mmHg in the first hour of treatment
    - This excludes patients with an underlying structural cause (e.g. an aneurysm), a GCS below 6 and those who are going for early neurosurgery
- Make patients nil by mouth until they have had a swallowing assessment
- Assess hydration and give fluids if dry
- Management of subarachnoid haemorrhage and raised intracranial pressure is addressed in a separate chapter

# Complications

- Decreased mobility e.g. hemiparesis or hemiplegia
- Seizures
- Delirium
- Hydrocephalus due to bleeding into the ventricles
- Cardiac complications e.g. arrhythmias
- Recurrence of haemorrhagic stroke
- Increased risk of infection e.g. aspiration pneumonia
- Increased risk of falls in the longer-term
- Incontinence
- Neuropathic or musculoskeletal pain
- Fatigue
- Cognitive decline

# Prognosis

- Mortality is significantly higher than in ischaemic stroke - approximately 30% at 30 days
- There is also a higher risk of recurrence; 3.2 per 100 patient years in haemorrhagic stroke
- Morbidity is also high - at 3-6 months after a haemorrhagic stroke only 20-30% of patients are able to live independently
- Poor prognostic factors include larger volume haemorrhages, old age, intraventricular bleeding and impaired consciousness at presentation

# NICE Guidelines

[NICE - Stroke and transient ischaemic attack in over 16s](https://www.nice.org.uk/guidance/ng128)

[NICE CKS - Stroke and TIA](https://cks.nice.org.uk/topics/stroke-tia/)

# References

[RCEM Learning - Stroke in the ED](https://www.rcemlearning.co.uk/reference/stroke-in-the-ed/)

[National Clinical Guideline for Stroke for the UK and Ireland](https://www.strokeguideline.org/)
 
[Patient UK - Cerebrovascular Events](https://patient.info/doctor/cerebrovascular-events)
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Haemorrhagic Stroke
Topic
39
Emergency Medicine
6473
Hypertension is the most common cause of spontaneous intracerebral haemorrhage.
An 80-year-old woman presents to the Emergency Department (ED) with confusion.

On assessment, her GCS is 13, and a neurological examination reveals reduced power and sensation in the right upper and lower limbs. No external injuries are evident.

An urgent CT head shows a haemorrhagic stroke affecting the thalamus.

Which of the following is the most likely aetiology of the stroke?
a