Do survivors of an acute hypertensive intraparenchymal hemorrhage need a structured follow‑up assessment for underlying cerebrovascular disease and secondary stroke prevention?

Assessment for Cerebrovascular Disease After Hypertensive Intracerebral Hemorrhage

Yes, survivors of acute hypertensive intraparenchymal hemorrhage require structured follow-up assessment for underlying cerebrovascular disease, but the extent depends critically on whether the hemorrhage occurred in typical hypertensive locations with clear hypertensive etiology—in which case additional vascular imaging may not be warranted—versus atypical presentations that mandate comprehensive vascular evaluation. 1

Risk Stratification: Who Needs Vascular Assessment?

Typical Hypertensive Hemorrhage (May NOT Need Additional Imaging)

In cases of typical hypertensive hemorrhage or cerebral amyloid angiopathy, additional vascular imaging may not even be warranted. 1

Typical hypertensive hemorrhage is characterized by:

• Location: Single deep hemorrhage in basal ganglia, thalamus, pons, or cerebellum 1
• Clinical history: Documented hypertension 1
• Imaging pattern: Consistent with hypertensive vasculopathy without atypical features 1

Atypical Presentations (REQUIRE Comprehensive Vascular Workup)

Obtain CTA, MRI/MRA, or catheter angiography if ANY of the following red flags are present: 2

Patient factors:

• Age <55-65 years 2
• Female sex 2
• Nonsmoker 2
• Lobar ICH location 2
• No history of hypertension 2

Clinical features:

• Prodrome of headache, neurologic or constitutional symptoms before hemorrhage 2

Radiologic red flags:

• Hemorrhage in atypical location (not typical hypertensive sites) 1
• Pure intraventricular hemorrhage (high prevalence of vascular lesions) 1

Recommended Vascular Imaging Strategy

First-Line Noninvasive Imaging

CTA of the head is the preferred initial vascular imaging modality, with sensitivity and specificity exceeding 90% for identifying culprit vascular lesions such as aneurysms or arteriovenous malformations. 1

• CTA should be performed for follow-up evaluation of underlying etiology in IPH 1
• MRI/MRA serves as an alternative or complementary modality 1

When to Escalate to Catheter Angiography

Catheter-directed arteriography is indicated when:

• Noninvasive imaging (CTA/MRA) is negative but clinical suspicion remains high for vascular malformation 1
• Hemorrhage occurred in non-typical hypertensive locations 1
• Pure intraventricular hemorrhage is present 1

Critical caveat: In one series of 89 patients with IPH in atypical locations who had negative CTA and MRI/MRA, catheter arteriography subsequently identified 7 arteriovenous malformations and 3 dural arteriovenous fistulas. 1

Timing consideration: Catheter arteriography in the acute period may miss vascular lesions that are detected by repeat arteriography several weeks later. 1

Secondary Stroke Prevention Assessment

Blood Pressure Management

Blood pressure management is the cornerstone of secondary ICH prevention, regardless of ICH location or underlying cerebral small vessel disease. 3

Antiplatelet Therapy Considerations

The decision to resume antiplatelet therapy requires careful individualized risk-benefit assessment:

• ICH survivors are at high risk of future major adverse cardiovascular events (MACE), including ischemic stroke and myocardial infarction 1, 3
• Current evidence from the RESTART trial provides reassurance about safety of antiplatelet monotherapy in high-risk ICH survivors with history of MACE or atrial fibrillation 1
• Antiplatelet combinations should be avoided as they increase ICH risk without necessarily lowering lacunar infarction risk 4

Ongoing Surveillance

Clinical and imaging predictors can inform stratification of ICH recurrence risk and identify patients at very high probability of future hemorrhagic events. 3

Common Pitfalls to Avoid

Do not assume all hypertensive hemorrhages are "typical": Always verify location, patient demographics, and clinical presentation match the expected pattern before forgoing vascular imaging. 1, 2

Do not miss delayed vascular lesions: If initial catheter angiography is negative in the acute period but clinical suspicion remains, consider repeat angiography several weeks later. 1

Do not overlook pure intraventricular hemorrhage: This presentation has a high prevalence of underlying vascular lesions and warrants catheter arteriography. 1

Do not restart anticoagulation without careful consideration: Anticoagulants increase the risk of potentially fatal ICH and should be avoided when possible, with nonpharmacological approaches (such as left atrial appendage closure) considered for atrial fibrillation. 4