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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 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.


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. ...

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