What are the differences in signs, symptoms, and treatment for cerebrovascular disease (CVD) infarct (ischemic stroke) versus CVD bleed (hemorrhagic stroke)?

Differences Between Cerebrovascular Disease (CVD) Infarct and CVD Bleed

The key differences between ischemic stroke (CVD infarct) and hemorrhagic stroke (CVD bleed) involve distinct signs, symptoms, and treatment approaches, with hemorrhagic strokes generally being more severe and having higher early mortality despite being less common.

Signs and Symptoms

Ischemic Stroke (CVD Infarct)

• Presents with focal neurological deficits that correspond to the affected vascular territory 1
• Common symptoms include:
  • Contralateral weakness or hemiparesis 1
  • Contralateral sensory loss or paresthesia 1
  • Visual field deficits (homonymous hemianopsia) 1
  • Speech disturbances (aphasia if dominant hemisphere affected) 1
  • Neglect (if non-dominant hemisphere affected) 1
• Symptoms typically have sudden onset and remain stable or improve gradually 1, 2
• Symptoms correlate with the specific arterial territory affected 1

Hemorrhagic Stroke (CVD Bleed)

• Generally presents with more severe neurological deficits compared to ischemic strokes 2
• Distinctive features include:
  • More severe headache (often described as "thunderclap") 1, 2
  • More frequent altered level of consciousness 1, 2
  • Higher likelihood of nausea and vomiting 2
  • Meningismus (neck stiffness) may be present, especially with subarachnoid hemorrhage 1
• Symptoms often progress over minutes to hours as the hematoma expands 2
• May have a bimodal peak of occurrence at 09:00 and 19:00, unlike the broader plateau pattern seen in ischemic strokes 3

Diagnostic Imaging

Ischemic Stroke

• Initial non-contrast CT head typically shows no abnormalities in the first few hours 1
• MRI with diffusion-weighted imaging shows restricted diffusion in affected areas early 1
• CT or MR angiography may identify arterial occlusion or stenosis 1
• Perfusion imaging can identify salvageable penumbra in early stages 1

Hemorrhagic Stroke

• Non-contrast CT head is essential and shows hyperdense blood collection immediately 1
• CTA may show "spot sign" indicating active bleeding, which has prognostic value 1
• MRI can help identify underlying causes such as amyloid angiopathy or vascular malformations 1
• MRV may be useful if cerebral venous thrombosis is suspected as the cause of hemorrhage 1

Treatment Approaches

Ischemic Stroke

• Acute management focuses on reperfusion strategies:
  • Intravenous thrombolysis (tPA) within appropriate time window 1
  • Endovascular thrombectomy for large vessel occlusions 1
• Secondary prevention includes:
  • Antiplatelet therapy (aspirin, clopidogrel) 1
  • Anticoagulation if cardioembolic source (e.g., atrial fibrillation) 1
  • High-dose statin therapy 4
  • Blood pressure management 1
  • Carotid revascularization if significant carotid stenosis 1

Hemorrhagic Stroke

• Acute management focuses on preventing hematoma expansion:
  • Blood pressure control is critical 1
  • Reversal of anticoagulation if applicable 1
  • Surgical evacuation in select cases with significant mass effect 1
• Antiplatelet and anticoagulant medications are typically contraindicated in the acute phase 4
• Statins are generally avoided following hemorrhagic stroke unless there is evidence of atherosclerotic disease or high cardiovascular risk 4
• Close monitoring for increased intracranial pressure and neurological deterioration 1

Prognosis and Mortality

• Hemorrhagic strokes have higher early mortality compared to ischemic strokes:
  • 4-fold higher risk in the first week 2
  • 2.5-fold higher risk after one week 2
  • 1.5-fold higher risk after three weeks 2
  • After 3 months, mortality rates become similar between stroke types 2
• Stroke severity is almost linearly related to the probability of having hemorrhagic stroke (30% in the most severe strokes vs. 2% in the mildest) 2
• Both stroke types can result in similar rehabilitation outcomes despite different pathophysiology 5

Risk Factors

• Factors more associated with ischemic stroke:

  • Diabetes 2
  • Atrial fibrillation 2
  • Previous myocardial infarction 2
  • Previous stroke 2
  • Intermittent arterial claudication 2

• Factors more associated with hemorrhagic stroke:

  • Smoking 2
  • Excessive alcohol consumption 2
  • Hypertension (particularly for deep hemorrhages) 1
  • Cerebral amyloid angiopathy (for lobar hemorrhages) 6

Clinical Pearls and Pitfalls

• Hemorrhagic transformation of ischemic stroke can occur, particularly after reperfusion therapy, complicating the clinical picture 1
• The ratio of hemorrhagic to ischemic stroke occurrence is highest in early morning (02:00-06:59) 3
• Ischemic stroke patterns differ between weekdays and weekends, with a broad plateau between 09:00-21:59 on weekdays but a unimodal peak at 14:00-15:59 on weekends 3
• Despite having different pathophysiologies, both stroke types ultimately result in ischemic brain injury, which may account for similar functional outcomes in rehabilitation 5
• The majority of cardiovascular events, including strokes, occur in patients with blood pressure <140/90 mmHg, emphasizing the importance of comprehensive risk factor management beyond just blood pressure control 7