How do you clinically determine the presence of a brain bleed?

Clinical Determination of Brain Bleeds

Rapid neuroimaging with CT or MRI is the recommended first-line approach to clinically determine the presence of a brain bleed, as clinical features alone are insufficient for diagnosis. 1, 2

Initial Assessment and Imaging

• Non-contrast CT head is the gold standard first-line diagnostic test for suspected brain hemorrhage with highest appropriateness rating (9/9) according to the American College of Radiology 2
• MRI with gradient echo (GRE) and T2* susceptibility-weighted imaging sequences is equally sensitive for detecting acute hemorrhage and can be used as an alternative (8/9 appropriateness rating) 1, 2
• Imaging should be performed as soon as possible after symptom onset, ideally within hours, as earlier imaging increases the likelihood of detecting active bleeding and potential hematoma expansion 2
• Among patients undergoing head CT within 3 hours of intracerebral hemorrhage (ICH) onset, 28-38% show hematoma expansion of greater than one-third on follow-up CT 1, 2

Clinical Features Suggesting Brain Hemorrhage

While clinical features alone cannot reliably distinguish hemorrhage from ischemia, certain signs increase suspicion for ICH:

• Vomiting 1
• Systolic blood pressure >220 mm Hg 1
• Severe headache 1
• Coma or decreased level of consciousness 1
• Rapid neurological progression over minutes or hours 1
• Focal neurological deficits with sudden onset 3

Neurological Evaluation Protocol

• Urgent neurological evaluation should include assessment of pupils and Glasgow Coma Scale (GCS) motor score 1
• A baseline severity score should be performed as part of the initial evaluation (Class I; Level of Evidence B) 2
• The National Institutes of Health Stroke Scale (NIHSS) provides quantification that allows easy communication of event severity 2
• Glasgow Coma Scale score is well-established and easily computed 2

Advanced Imaging for Secondary Causes

• CT angiography (CTA) and contrast-enhanced CT may help identify patients at risk for hematoma expansion (Class IIb, Level of Evidence B) 1, 2
• CTA, CT venography, contrast-enhanced MRI, magnetic resonance angiography and venography can evaluate underlying structural lesions including vascular malformations and tumors 1, 2
• Consider magnetic resonance venography or CT venography if hemorrhage location, relative edema volume, or abnormal signal in cerebral sinuses suggests cerebral vein thrombosis 1, 2
• Catheter angiography may be considered if clinical suspicion is high or non-invasive studies suggest an underlying vascular cause 1, 2

Radiological Features Suggesting Secondary Causes

• Presence of subarachnoid hemorrhage 2
• Unusual (non-circular) hematoma shape 1, 2
• Presence of edema out of proportion to the early time of imaging 1, 2
• Unusual hemorrhage location 1, 2
• Presence of other abnormal structures in the brain like a mass 1, 2

Follow-up Imaging

• Follow-up imaging is recommended in the event of abrupt neurologic deterioration to evaluate for hematoma expansion 2
• Non-contrast cerebral CT or MRI should be performed at defined time points after initial diagnosis (commonly at 24 hours, 7-10 days, 30 days, and 90 days) 2

High-Risk Populations

• Patients on oral anticoagulants constitute 12-14% of patients with ICH, and this proportion appears to be increasing 1
• Patients with lobar hemorrhage location, age <55 years, and no history of hypertension have higher likelihood of secondary causes requiring additional MRI beyond non-contrast CT 2
• Warfarin-related hemorrhages are associated with increased hematoma volume, greater risk of expansion, and increased morbidity and mortality 2

Common Pitfalls to Avoid

• Relying solely on clinical features to differentiate hemorrhage from ischemia - neuroimaging is mandatory 1, 2
• Delaying imaging in patients with suspected brain hemorrhage can miss the opportunity to identify active bleeding 1, 2
• Failing to consider secondary causes of hemorrhage in patients with atypical presentations or risk factors 2
• Not performing follow-up imaging in patients with clinical deterioration, which may miss hematoma expansion 2