Make the Diagnosis: Does This Patient Have a Hemorrhagic Stroke?
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 78-1Useful Findings for Diagnosing Hemorrhagic Strokea ||Download (.pdf) Table 78-1 Useful Findings for Diagnosing Hemorrhagic Strokea
| ||LR+ (95% CI) ||LR- (95% CI) |
| ||Clinical Examination |
|Risk Factors |
|Prior transient ischemic attack ||0.34 (0.18-0.65) ||1.2 (1.1-1.3) |
|Symptoms || || |
|Seizures ||4.7 (1.6-14) ||0.93 (0.9-0.96) |
|Vomiting ||3.0 (1.7-5.5) ||0.73 (0.59-0.91) |
|Headache ||2.9 (1.7-4.8) ||0.66 (0.52-0.82) |
|Level of consciousness || || |
| Coma ||6.2 (3.2-12) |
| Drowsy ||2.0 (1.0-3.9) |
| Alert ||0.35 (0.24-0.5) |
|Neck stiffness ||5.0 (1.9-13) ||0.83 (0.75-0.92) |
|Diastolic blood pressure >110 mm Hg3 ||4.3 (1.4-14) ||0.59 (0.39-0.89) |
|Cervical bruit4 ||0.12 (0.03-0.47) ||1.1 (1.0-1.1) |
| ||Laboratory Examination |
|Xanthochromia in cerebrospinal fluid5 ||15 (7.7-29) ||0.31 (0.19-0.49) |
Diagnostic certainty requires neuroimaging with computed tomography favored as the initial test because the images can be obtained rapidly.