Stroke, Hemorrhagic

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.

Reference Standard Tests

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

References