Hemorrhagic Stroke (Cerebrovascular Accident, CVA) —

Symptoms and Treatment The most common stroke is an ischemic stroke, while the

Definition of Hemorrhagic Stroke second most common cause is a hemorrhagic

stroke. Hemorrhagic stroke is implicated in about 15% of

all stroke cases. Mortality rates associated with intracerebral

hemorrhage are considered significantly higher than ischemic

stroke.

Hemorrhagic stroke mortality seems to be highest within the

first three weeks after the event. Current estimates indicate the

Image: “An intraparenchymal bleed with surrounding mortality risk is similar for both hemorrhagic and ischemic
edema.” by James Heilman, MD. License: CC BY-SA 4.0
strokes 3 months after the CVA.
A stroke/cerebrovascular accident (CVA) is characterized by
Hypertension is considered the most common cause of
the rapid appearance of a focal deficit of the brain, with or
spontaneous intracerebral hemorrhage in adults. Cerebral
without higher cerebral dysfunctions, such as aphasia,
amyloid angiopathy, cerebrovascular
hemisensory loss, and visual field defects. A CVA can either
malformations, arteriovenous
be an ischemic stroke (more than 85% of cases) or a
malformations, and neoplastic disease are other risk factors
hemorrhagic stroke (fewer than 15% of cases).
for hemorrhagic stroke.
The simplest definition of hemorrhagic stroke is an acute
Cerebral aneurysms are more commonly associated
neurologic injury as a consequence of intracranial
with subarachnoid hemorrhage rather than intracerebral
bleeding.
Classification of hemorrhagic strokes hemorrhage; however, up to 30% of bleeding aneurysms

Per the definition above, the bleeding might be: might cause an intracerebral hemorrhage.
1. Within the parenchyma, also known as intracerebral
hemorrhage Risk factors are:
2. In the cerebrospinal fluid surrounding the brain,  Hypertension
known as subarachnoid hemorrhage  AVMs
 Cocaine use
Epidural and subdural hemorrhages are not considered part of  Amyloid angiopathy
 Metastatic tumors
the hemorrhagic stroke spectrum. Etiology of Hemorrhagic Stroke
Hemorrhagic strokes are also classified based on the area Several diseases might be complicated by hemorrhagic stroke.
of the brain involved: The most common etiology of primary intracerebral
 The basal ganglia (66%)
 Thalamus hemorrhage is hypertension. Prolonged
 Cerebellum
hypertension increases the pressure on the small arteries
Hemorrhagic stroke may also be classified based on the
arising from the middle cerebral, thalamic, and pontine
vessel involved in:
 Anterior circulation stroke arteries. This increased pressure leads to intimal
 Posterior circulation stroke
hyperplasia, degeneration, and eventually necrosis of the
 Large vessel disease
 Small vessel disease small arteries. At some point, the small arteries

can rupture, and intracerebral bleeding occurs.

 hemorrhagic infarction. A parenchymal hematoma might

form, which can have drastic consequences on the patient’s

clinical outcome.

Aneurysmal rupture is more likely to be associated with

subarachnoid hemorrhage rather than intracerebral

Image: “Hemorrhagic Stroke.” by National Heart Lung and
Blood Institute (NIH). License: Public Domain hemorrhage. Patients usually are younger and describe
People older than 60 years of age are at risk of a sudden-onset severe headache.
developing cerebral amyloid angiopathy, another condition
Clinical Presentation of Hemorrhagic Stroke
commonly associated with hemorrhagic stroke. Beta-

amyloid is deposited in small and medium-sized cerebral Patients who develop subarachnoid hemorrhage and remain

arteries, especially in the basal ganglia. The affected blood conscious usually describe a severe headache that is

vessels degenerate and undergo necrosis, which puts them at classically described as the worst headache in their lives. In

risk of rupture. If the vessels rupture, the patient will develop addition to the severe headache, patients usually

an intracerebral hemorrhage. have nausea or vomiting. Focal neurological

Developmental venous anomalies, arteriovenous deficits and impaired consciousness are also associated with

malformations, capillary telangiectasias, and cavernous hemorrhagic stroke. Seizures due to cortical irritation by the

malformations result from abnormal fragile blood vessels. blood can occur. Patients can also develop neck

These blood vessels can bleed and cause an intracerebral rigidity and fever, which are signs suggestive of meningism.

hemorrhage. Larger arteriovenous malformations have deep Intracerebral hemorrhage can cause headaches and nausea.

venous drainage, are in the eloquent cortex, and are very likely However, more often, it is impossible to differentiate

to bleed. intracerebral hemorrhage and ischemic stroke based on

Neoplastic tissue is hypervascular, and these blood vessels the clinical picture. Focal neurological deficits, impaired

are usually pathological. They are fragile, can consciousness, and the sudden onset of semiology occur in

undergo necrosis, and put the patient at risk of intracerebral both ischemic and hemorrhagic strokes.

bleeding. The most common cause of neoplastic related Because of the overlap of the symptoms between

intracerebral hemorrhage is metastatic brain disease from hemorrhagic and ischemic strokes, prompt and early brain

melanomas, lungs, kidneys, and thyroid gland. imaging is essential for differentiating between the two

Pituitary adenoma, glioblastoma, and ependymoma are the conditions because they have different treatment plans.

most common primary brain tumors associated with

Diagnostic Workup for Hemorrhagic Stroke
intracerebral hemorrhage.
Computed tomography without contrast remains the first-
Hemorrhagic infarction is defined as the transformation of
line diagnostic imaging modality to evaluate the acute stroke
an ischemic infarct into a hemorrhagic infarct. The blood
patient despite recent advances in magnetic resonance
vessels within the ischemic brain tissue are fragile and can
imaging. Computed tomography imaging in acute
rupture. If this happens, the patient might develop a
 Treatment of Hemorrhagic Stroke
hemorrhagic stroke due to hypertension reveals an oval or
The management of hemorrhagic stroke depends on the
round hyperintense mass.
hematoma size, hematoma expansion rate, and

the computed tomography angiography sign.

Patients with large intracerebral hematomas are at the

highest risk of immediate and 30-day mortality. Medical

management mainly consists of anticonvulsants to prevent

seizures, anti-hypertensive drugs to lower the blood pressure

in case of hypertension, and osmotic diuretics. The decision

to lower systolic blood pressure in acute intracerebral

Image: “Subarachnoid hemorrhage in CT. One can see the
blood hyperattenuating in the basal cisterns.” by Hellerhoff. hemorrhage of <140 to <180 mm Hg or below is still under
License: CC BY-SA 3.0
extensive research.
If the patient presents very early in the disease process, the
Patients with posterior fossa intracerebral
mass might be heterogeneous due to ongoing bleeding.
hemorrhage usually have a worse prognosis; therefore, early
Patients presenting in the subacute stage can have an isodense
surgical intervention for decompression is recommended.
mass instead of the typical hyperdense mass seen in acute
Patients who have hematoma expansion on repeated imaging
hemorrhagic stroke.
might need Factor VII infusion.
Patients who undergo magnetic resonance imaging with a
Patients who have small, 1 to 2 mm foci of intense
new device that is fast enough for emergencies can have a
enhancement inside the hematoma on computed tomography
hyperintense or isointense mass in the hyperacute and acute
angiography are most likely to have ongoing bleeding and
stages. In the subacute stage, up to one week after the
may benefit from embolization therapy in addition to better
hemorrhagic event, a hyperintense mass will remain visible on
blood pressure control. Additionally, these patients are at an
magnetic resonance imaging. At the chronic stage, the picture
increased risk of hematoma expansion; hence, the decision
becomes similar to chronic ischemic stroke, i.e. hypointense.
to monitor them more closely with repeated brain imaging is
Computed tomography imaging is also helpful in the
justifiable.
diagnostic work-up of patients presenting with subarachnoid
Managing subarachnoid hemorrhage is largely dependent
hemorrhage. The typical picture of subarachnoid hemorrhage
on blood pressure control and decreasing intracranial
on computed tomography is that of hyper-attenuation that is
pressure by osmotic diuresis.
confined to the subarachnoid space. The hyperintensity is
Patients with subarachnoid hemorrhage due to head
present within the sulci, fissures, and basal cisterns.
trauma usually have a slightly better prognosis than those
Magnetic resonance imaging can also show hyperintensity in
with aneurysmal subarachnoid hemorrhage. Patients should
the subarachnoid space in the case of subarachnoid
receive good analgesia, but opioids should be avoided if
hemorrhage.
possible because they mask signs of neurological signs of

ongoing bleeding.