What is the diagnostic approach for hemorrhagic stroke in an acute setting?

From the Guidelines

To diagnose a hemorrhagic stroke in an acute setting, immediate non-contrast computed tomography (CT) scan of the brain is the first-line diagnostic test due to its speed, availability, and high sensitivity for detecting acute blood, as recommended by the most recent guidelines 1. The patient should be rapidly assessed using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) while obtaining a focused history of symptom onset, risk factors, and medication use (particularly anticoagulants). Some key points to consider in the diagnostic approach include:

• Vital signs should be closely monitored, with attention to blood pressure which is often elevated.
• Laboratory tests including complete blood count, coagulation studies (PT, PTT, INR), and basic metabolic panel should be ordered.
• If the initial CT is negative but clinical suspicion remains high, CT angiography, CT perfusion, or magnetic resonance imaging (MRI) may be warranted.
• In some cases, lumbar puncture might be considered if subarachnoid hemorrhage is suspected but not visualized on imaging. The diagnostic approach must be expedited as hemorrhagic strokes require urgent management, potentially including blood pressure control, reversal of anticoagulation, neurosurgical consultation, and consideration for interventional procedures depending on the cause and extent of bleeding, with the goal of minimizing morbidity, mortality, and improving quality of life 1. Key considerations in the management of hemorrhagic stroke include:
• Differentiating between hemorrhagic and ischemic stroke to guide further management.
• Identifying the location and extent of the hemorrhage to inform treatment decisions.
• Assessing the patient's overall clinical condition and potential risks and benefits of treatment. It is essential to prioritize the most recent and highest quality evidence in guiding diagnostic and management decisions for hemorrhagic stroke, with the ultimate goal of optimizing patient outcomes in terms of morbidity, mortality, and quality of life 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosing Hemorrhagic Stroke in Acute Setting

To diagnose hemorrhagic stroke in an acute setting, the following steps can be taken:

• Identify the patient's symptoms and medical history, including the presence of hypertension, atrial fibrillation, and oral anticoagulant use 2, 3
• Perform a noncontrast head CT scan to identify hemorrhage, which is the most common initial neuroimaging study 3, 4, 5, 6
• Use the patient's medical history, neurologic examination, and laboratory studies to guide further neuroimaging studies, such as CT angiography (CTA), CT perfusion, MRI, and magnetic resonance angiography (MRA) 3, 4, 5, 6
• Apply risk stratification models, which derive from findings on clinical exam and neuroimaging, to predict patient outcomes and guide treatment decisions 2

Neuroimaging Techniques

The following neuroimaging techniques can be used to diagnose and manage hemorrhagic stroke:

• Noncontrast head CT: sensitive for hemorrhage and widely available 3, 4, 5, 6
• CT angiography (CTA): used to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease 4, 6
• CT perfusion: used to identify salvageable brain tissue and guide endovascular therapy 4, 6
• MRI and MRA: provide valuable insights for outcomes prognostication and stroke etiology 4, 5, 6

Importance of Neuroimaging

Neuroimaging is essential for:

• Identifying hemorrhagic stroke and determining the underlying etiology 3
• Preventing hematoma expansion and treating acute complications 3
• Guiding medical, surgical, and interventional management 3
• Prognostication and directly impacting patient care 3, 4, 5, 6