What are the signs and assessment findings associated with a hemorrhagic stroke?

From the Guidelines

Hemorrhagic strokes are characterized by distinct signs and assessment findings, including sudden onset of severe headache, nausea and vomiting, altered level of consciousness, and focal neurological deficits, which require immediate medical attention to improve outcomes. The clinical presentation of hemorrhagic stroke, as described in the guidelines for the management of spontaneous intracerebral hemorrhage in adults 1, includes the onset of a sudden focal neurological deficit while the patient is active, which progresses over minutes to hours. This smooth symptomatic progression of a focal deficit over a few hours is uncommon in ischemic stroke and rare in subarachnoid hemorrhage. Headache is more common with ICH than with ischemic stroke, although less common than in subarachnoid hemorrhage. Vomiting is more common with ICH than with either ischemic stroke or subarachnoid hemorrhage. Increased blood pressure and impaired level of consciousness are common.

Some key signs and assessment findings associated with hemorrhagic stroke include:

• Sudden onset of severe headache
• Nausea and vomiting
• Altered level of consciousness, ranging from confusion to coma
• Focal neurological deficits, such as hemiparesis, facial drooping, speech disturbances, vision changes, and balance or coordination problems
• Vital sign abnormalities, including elevated blood pressure
• Meningeal irritation signs, such as neck stiffness and photophobia, particularly with subarachnoid hemorrhage
• Rapid progression of symptoms compared to ischemic strokes
• Signs of increased intracranial pressure, including decreased pupillary response, Cushing's triad, and papilledema on fundoscopic examination.

The severity of symptoms generally correlates with the size and location of the bleed, with larger hemorrhages causing more profound deficits, as noted in the guidelines for the management of spontaneous intracerebral hemorrhage 1. Immediate medical attention is crucial as hemorrhagic strokes have a higher mortality rate than ischemic strokes, and early intervention can significantly improve outcomes. Neuroimaging, such as CT and MRI, is essential for diagnosis and identifying potential causes of hemorrhage, including arteriovenous malformations, tumors, and cerebral vein thrombosis 1.

From the Research

Signs and Assessment Findings of Hemorrhagic Stroke

The signs and assessment findings associated with a hemorrhagic stroke can be identified through various studies. Some of the key findings include:

• Headache, vomiting, and altered mental status are common presenting symptoms of hemorrhagic stroke 2, 3
• Focal limb weakness, facial weakness, and slurred speech are less common in hemorrhagic stroke compared to ischemic stroke 2
• A decreased Glasgow Coma Scale (GCS) score is often seen in patients with hemorrhagic stroke, with 38% having a GCS score less than 14 and 19% having a GCS score less than 8 2
• Neck stiffness, seizures accompanying the neurologic deficit, and diastolic blood pressure greater than 110 mm Hg can increase the probability of hemorrhagic stroke 3
• Coma, with a likelihood ratio of 6.2, is a significant finding that increases the probability of hemorrhagic stroke 3

Diagnostic Accuracy of Clinical Examination

The diagnostic accuracy of bedside findings in distinguishing hemorrhagic stroke from ischemic stroke has been systematically reviewed. The results show that:

• Certain findings, such as coma, neck stiffness, and seizures, can increase the probability of hemorrhagic stroke 3
• Other findings, such as cervical bruit and prior transient ischemic attack, can decrease the probability of hemorrhage 3
• The Siriraj score can be used to increase or decrease the probability of hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients 3

Imaging and Diagnostic Evaluation

Imaging options, such as computed tomography or autopsy, are required to distinguish hemorrhagic stroke from ischemic stroke. The expected imaging findings for each modality can help guide patient management 4. Additionally, advanced imaging can readily diagnose the entities that compose hemorrhagic stroke, including intracerebral and subarachnoid hemorrhage 4.