Skip to Main Content

++

Make the Diagnosis: Does This Patient Have a Hemorrhagic Stroke?

++

Prior Probability

++

Once a patient has had a stroke1 (see Table 48-10 in Chapter 48: Stroke), the clinician must move quickly to identify those with hemorrhagic etiologies. While most strokes are ischemic, the prevalence of hemorrhagic stroke is 24%, though there is geographic variability with studies from the United States and Europe showing a lower prevalence of 15% (95% CI, 24%-35%).2 Less than 3% of patients will have conditions that mimic stroke (eg, a tumor, subdural hematoma, or intracranial infection).

++

Population in Whom Hemorrhagic Stroke Should Be Considered

++

Because the treatment is different, the possibility of a hemorrhagic stroke should be considered in all patients who have a clinical diagnosis of stroke.

++

Assessing the Likelihood of Hemorrhagic Stroke

++

The association of specific symptoms and signs with likelihood of hemorrhagic stroke a presented in Table 78-1. A prior transient ischemic attack makes a hemorrhagic stroke less likely. Seizures, vomiting, and headache are symptoms that make a hemorrhagic stroke more likely. Signs of worsening levels of consciousness, neck stiffness, or diastolic blood pressure >110 mm Hg, and xanthochromia in cerebrospinal fluid make a hemorrhagic stroke more likely. The presence of a cervical bruit makes a hemorrhagic stroke less likely. However, no individual risk factor, symptom, or sign is accurate enough that its presence or absence clinches the diagnosis. Unfortunately, the clinician's overall impression of a hemorrhagic stroke (LR+, 6.2; 95% CI, 4.2-9.3; LR-, 0.28 [0.20-0.39]) performs no better than the individual findings in establishing the diagnosis6 so that a reference standard test is required when diagnostic certainty is necessary.

++
Table Graphic Jump Location
Table 78-1Useful Findings for Diagnosing Hemorrhagic Strokea
++

Reference Standard Tests

++

Diagnostic certainty requires neuroimaging with computed tomography favored as the initial test because the images can be obtained rapidly.

++

References

1. +
Goldstein  LB, Simel  DL. Is this patient having a stroke? JAMA[JAMA and JAMA Network Journals Full Text]. 2005;293(19):2391–2402.
[PubMed: 15900010]
2. +
Runchey  S, McGee  S. Does this patient have ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

JAMAevidence Full Site: One-Year Subscription

Connect to the full suite of JAMAevidence content and resources including interactive self-assessment, videos, and more.

$495 USD
Buy Now

Pay Per View: Timed Access to all of JAMAevidence

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.