How do you differentiate and manage a suspected stroke, specifically hemorrhagic vs ischemic, based on clinical presentation?

Differentiating Hemorrhagic vs Ischemic Stroke: Clinical Approach

Neuroimaging is absolutely mandatory to differentiate ischemic stroke from intracerebral hemorrhage—clinical features alone have inadequate sensitivity and specificity to guide treatment decisions, and attempting to treat based on clinical presentation alone can be catastrophic. 1, 2, 3

Immediate Diagnostic Protocol

Non-contrast CT head must be completed within 25-30 minutes of hospital arrival to distinguish ischemic from hemorrhagic stroke. 1, 3 The entire evaluation from door to imaging interpretation to treatment decision must occur within 60 minutes for patients eligible for thrombolysis. 1

• CT is the gold standard for detecting acute hemorrhage and is the most practical first-line imaging modality. 1
• The goal is CT completion within 25 minutes of ED arrival with interpretation within an additional 20 minutes (door-to-interpretation time of 45 minutes). 4
• MRI with diffusion-weighted imaging (DWI) has 88-100% sensitivity and 95-100% specificity for detecting acute ischemia, but time, cost, and availability often preclude emergent MRI. 4, 1

Clinical Features Suggesting Hemorrhage (But Never Diagnostic)

While these findings increase the probability of hemorrhagic stroke, none are definitively diagnostic and all patients require imaging: 5

Findings that significantly increase hemorrhage probability:

• Coma or severely decreased level of consciousness (likelihood ratio 6.2) 5, 1
• Neck stiffness (likelihood ratio 5.0) 5
• Seizures accompanying the neurologic deficit (likelihood ratio 4.7) 5
• Systolic blood pressure >220 mmHg or diastolic >110 mmHg (likelihood ratio 4.3) 5, 1
• Vomiting (likelihood ratio 3.0) 5, 1
• Severe headache (likelihood ratio 2.9) 5, 1
• Symptom progression over minutes to hours 1

Findings that decrease hemorrhage probability:

• Cervical bruit (likelihood ratio 0.12) 5
• Prior transient ischemic attack (likelihood ratio 0.34) 5

Critical limitation: 20% of stroke patients have diagnostically unhelpful clinical presentations, and many patients with hemorrhage lack any of these findings. 5

Essential Concurrent Evaluations (Do Not Delay Imaging)

Perform these in parallel with imaging, but never delay imaging or thrombolytic therapy while awaiting results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use: 4, 1

• Blood glucose (hypoglycemia can mimic stroke) 4, 1
• Complete blood count with platelet count 4, 1
• PT/INR and aPTT 4, 1
• Serum electrolytes and renal function 4, 1
• 12-lead ECG and cardiac biomarkers (acute MI can cause stroke; stroke can cause MI) 4, 1
• NIHSS score to quantify stroke severity and guide treatment decisions 4, 1
• Document exact time of symptom onset or last known well—this determines eligibility for time-sensitive therapies 4, 1

Management Based on Imaging Results

If Ischemic Infarct Confirmed on CT:

Thrombolysis eligibility (if within 3 hours of symptom onset): 1

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) if no contraindications 1
• Blood pressure must be reduced to <185/110 mmHg before rtPA administration 4, 1
• Maintain BP <180/105 mmHg for 24 hours post-treatment 1
• Achieve door-to-needle time ≤30 minutes 1

If NOT eligible for thrombolysis: 4, 1

• Start aspirin 160-300 mg within 48 hours of symptom onset (typically after 24 hours if thrombolysis was given) 1
• Avoid aggressive BP lowering unless >220/120 mmHg—permissive hypertension may maximize cerebral blood flow 4, 1

Follow-up imaging: 4

• Subsequent CT is often obtained if the patient worsens neurologically and may be especially helpful in identifying hemorrhagic transformation following rtPA administration 4

If Intracerebral Hemorrhage Confirmed on CT:

Immediate actions: 1

• Immediately discontinue and reverse any anticoagulation 1
• Never administer aspirin, heparin, or any antithrombotic therapy 1, 2

Blood pressure management: 1

• For spontaneous ICH with hypertension presenting within 6 hours: reduce systolic BP acutely to target of 140 mmHg (strictly avoiding SBP <110 mmHg) 1

Surgical considerations: 1

• Consider external ventricular drainage if hydrocephalus with decreased level of consciousness develops 1

Critical Pitfalls to Avoid

• Never assume stroke type based on severity alone—there is substantial overlap between hemorrhagic and ischemic strokes. 2
• Never treat empirically with aspirin before imaging—the risk of expanding an intracranial hemorrhage outweighs potential benefits. 2
• Never delay transfer to obtain laboratory studies that won't change immediate management. 1, 2
• Do not rely on clinical scoring systems alone (e.g., Siriraj score)—while a score >1 increases hemorrhage probability (likelihood ratio 5.7), 20% of patients have indeterminate scores. 5

Special Circumstances: Rural/Limited Resource Settings

If CT is unavailable: 2, 3

• Activate emergency medical services immediately for transfer to the nearest stroke center with imaging capabilities 2, 3
• Notify the receiving facility in advance to activate their stroke team 2
• Consider air medical transport if ground transport times would exceed critical treatment windows 2
• Do NOT administer aspirin, heparin, or any antithrombotic therapy until hemorrhage is excluded by imaging 2
• Direct transport to a comprehensive stroke center if total transport time from scene does not exceed 60 minutes 2