What is the diagnostic evaluation and management approach for a young patient presenting with hemorrhagic stroke?

Diagnostic Evaluation of Hemorrhagic Stroke in a Young Patient

Immediate Neuroimaging

Non-contrast CT scan of the head must be obtained immediately upon presentation—this is the mandatory first-line imaging study to confirm hemorrhage, determine location, and assess extent. 1, 2, 3 This takes absolute priority over all other diagnostic tests and should be completed within 25 minutes of arrival. 1

• CT is preferred initially because of widespread availability, speed, and high diagnostic accuracy for acute hemorrhage 1
• MRI with gradient echo sequences can detect hyperacute hemorrhage with equivalent accuracy to CT and is superior for detecting chronic hemorrhage, but should not delay initial diagnosis 4

Vascular Imaging to Identify Underlying Etiology

In young patients with hemorrhagic stroke, CT angiography (CTA) or MR angiography (MRA) should be performed urgently to identify underlying vascular lesions, as approximately 48% of pediatric hemorrhagic strokes are caused by arteriovenous malformations or fistulas. 1

Specific vascular imaging approach:

• CTA of the head should be obtained within the first few hours to identify arteriovenous malformations, aneurysms, or other vascular abnormalities 1
• MRA provides noninvasive vascular assessment and can demonstrate malformations or aneurysms, though it lacks the temporal information of catheter angiography 1
• Catheter angiography remains the gold standard for high-flow vascular malformations and aneurysms and should be strongly considered in young patients when initial noninvasive imaging is negative or equivocal 1

Critical caveat for young patients:

In pediatric and young adult hemorrhagic stroke, the differential diagnosis differs substantially from older adults. The most common causes include: 1

• Arteriovenous malformations or fistulas (48%)
• Brain tumors (15%)
• Genetic or acquired coagulopathy (9%)
• Cavernous malformations (5%)
• Aneurysms (2%)

Laboratory Evaluation

Urgent blood work must include complete blood count with platelet count, coagulation studies (PT/INR, aPTT), and glucose. 1, 2, 5

Additional laboratory tests for young patients: 1

• Toxicology screen and blood alcohol level (substance abuse is a consideration in young adults)
• Pregnancy test in women of childbearing age
• Liver function tests if coagulopathy or malignancy suspected
• Troponin (elevated levels associated with increased mortality) 1

Advanced Imaging for Specific Scenarios

When initial vascular imaging is negative:

If CTA/MRA is negative but clinical suspicion remains high for vascular etiology, proceed to catheter angiography. 1 This is particularly important because:

• Small-vessel vasculitis may not be visible on noninvasive imaging 1
• Distal arterial branch lesions are better visualized on conventional angiography 1
• Extracranial arterial dissections, especially posterior circulation, can be missed on MRA 1

For suspected vasculitis:

• MRI typically shows progressive multifocal parenchymal lesions on T2-weighted imaging 1
• Catheter angiography is most sensitive for large-to-medium vessel vasculitis but will be negative in small-vessel disease 1
• Brain biopsy may be required for definitive diagnosis of small-vessel vasculitis (childhood primary angiitis of the CNS) 1

Monitoring for Hematoma Expansion

Serial head CT should be performed within the first 24 hours to evaluate for hemorrhage expansion, which occurs in 30-40% of patients and predicts poor outcome. 1, 3

• Repeat imaging is particularly important in patients with decreased level of consciousness or neurological deterioration 1
• The "spot sign" on CTA (contrast extravasation) identifies patients at high risk for expansion 1, 6

Referral Patterns

Young patients with hemorrhagic stroke require referral to a comprehensive stroke center (level three facility) for: 1

• Neurosurgical evaluation and potential intervention
• Catheter angiography and possible endovascular treatment
• Advanced cardiac evaluation (transesophageal echocardiography) if cardioembolic source suspected
• Comprehensive workup when no cause is identified at initial evaluation

Common Pitfalls to Avoid

• Do not delay vascular imaging while waiting for other test results—underlying vascular lesions require urgent identification 1, 3
• Do not assume hypertension is the cause in young patients—structural vascular lesions are far more common than in older adults 1
• Do not stop at negative CTA/MRA—proceed to catheter angiography if clinical suspicion remains high, as noninvasive imaging can miss small or distal lesions 1
• Be aware that cavernomas and capillary telangiectasias are angiographically occult and require MRI with susceptibility-weighted imaging for detection 1
• Consider hereditary hemorrhagic telangiectasia in patients with multiple small hemorrhages—contrast-enhanced MRI may be required 1