What are the diagnostic criteria for a hemorrhagic stroke?

From the Guidelines

Hemorrhagic stroke is diagnosed through a combination of clinical assessment and neuroimaging, with the primary diagnostic criteria including sudden onset of neurological deficits and confirmation of bleeding in the brain via CT scan, which is the gold standard initial imaging test, as recommended by the American Heart Association/American Stroke Association 1. The diagnostic criteria for a hemorrhagic stroke include:

• Sudden onset of neurological deficits, such as weakness, numbness, speech difficulties, vision problems, or severe headache
• Confirmation of bleeding in the brain via CT scan, which is the gold standard initial imaging test
• Laboratory tests, including complete blood count, coagulation studies (PT, PTT, INR), and electrolytes
• Blood pressure measurement, as hypertension is a common cause
• Evaluation of risk factors, such as hypertension, anticoagulant use, vascular malformations, or substance abuse
• Use of the Glasgow Coma Scale to assess consciousness level and the National Institutes of Health Stroke Scale to quantify stroke severity
• Consideration of lumbar puncture if subarachnoid hemorrhage is suspected but not visible on imaging, and angiography to identify underlying vascular abnormalities, as suggested by the Canadian Stroke Best Practice Recommendations 1. The importance of prompt diagnosis and accurate differentiation between ischemic and hemorrhagic stroke is emphasized, as thrombolytic therapy used for ischemic strokes would be harmful in hemorrhagic cases, and the management of hemorrhagic strokes requires a different approach, as highlighted in the guidelines for the early management of patients with ischemic stroke 1. Some key points to consider in the diagnosis of hemorrhagic stroke include:
• The use of CT angiography and contrast-enhanced CT to identify patients at high risk of hematoma expansion, as recommended by the American Heart Association/American Stroke Association 1
• The importance of evaluating for risk factors, such as hypertension, anticoagulant use, and vascular malformations, as suggested by the Canadian Stroke Best Practice Recommendations 1
• The use of the National Institutes of Health Stroke Scale to quantify stroke severity and predict outcomes, as recommended by the guidelines for the early management of patients with ischemic stroke 1
• The consideration of lumbar puncture and angiography in certain cases, as suggested by the imaging recommendations for acute stroke and transient ischemic attack patients 1.

From the Research

Diagnostic Criteria for Hemorrhagic Stroke

The diagnostic criteria for hemorrhagic stroke involve a combination of clinical presentation, medical history, and neuroimaging studies.

• The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure 2.
• A noncontrast head CT is the most common initial neuroimaging study, which allows for the identification of hemorrhage 3.
• The pattern of blood and the patient's medical history, neurologic examination, and laboratory studies lead the practitioner to pursue further neuroimaging studies to guide the medical, surgical, and interventional management 3.
• Neuroimaging studies, such as CT or MR imaging, are necessary for the identification of hemorrhagic stroke and provide information about its cause 4.
• The appearance of intracranial hematoma (ICH) on CT and MR imaging evolves over time and must be understood to facilitate accurate diagnosis 4.

Neuroimaging Studies

• Noncontrast head CT is the most common initial neuroimaging study for diagnosing hemorrhagic stroke 3.
• MR imaging alone may be adequate to identify hemorrhagic stroke in the acute setting, and is superior to CT for identification of chronic microbleeds and hemorrhagic conversion of infarction 4.
• CT angiography can help detect stenosis or occlusion of extra- and intracranial arteries 5.
• Perfusion CT provides information about brain perfusion, which permits differentiation of irreversibly damaged brain tissue from reversibly impaired "tissue at risk" 5.

Diagnostic Evaluation

• When patients present to the emergency room with sudden onset of focal neurologic symptoms or altered consciousness, hemorrhagic stroke is a major focus of emergency diagnostic evaluation 6.
• The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging 2.
• The clinical presentation, medical history, and neuroimaging studies are used to determine the underlying etiology of the hemorrhagic stroke 3.