Haemorrhagic stroke

Related Subjects: |Subarachnoid Haemorrhage |Perimesencephalic Subarachnoid haemorrhage |Haemorrhagic stroke |Cerebellar Haemorrhage |Putaminal Haemorrhage |Thalamic Haemorrhage |ICH Classification and Severity Scores |Acute Hydrocephalus

🧠 Introduction

• Haemorrhagic stroke, also called Spontaneous Intracerebral Haemorrhage (SICH), is often sudden and devastating.
• Accounts for ~15% of all strokes (majority are ischaemic).
• One subtype is Subarachnoid Haemorrhage (SAH), usually from ruptured aneurysms or vascular anomalies (discussed separately).
• ⚠️ Mortality is high: 30–50% of patients with large bleeds die within 30 days.
• Smaller bleeds can have better outcomes → focus on identifying cause and preventing recurrence.
• ❌ Traumatic intracranial haemorrhage and extra-axial bleeds (subdural, extradural) are not classified as stroke.

🔬 Pathological Appearance

On pathology and imaging, haemorrhagic strokes show destructive haematomas, surrounding oedema, and pressure effects:

⚙️ Aetiology

• Vessel rupture: Can occur anywhere from Circle of Willis arteries to small penetrating arterioles, capillaries, and draining veins.
• Aneurysms: Berry aneurysm rupture → high-pressure SAH.
• Small vessel disease: Hypertension → lipohyalinosis, Charcot–Bouchard microaneurysms → deep bleeds.
• Cerebral amyloid angiopathy: In elderly → lobar bleeds.
• Structural: AVMs, cavernomas, hereditary haemorrhagic telangiectasia.
• Neoplastic: Tumours (esp. melanoma, RCC, thyroid, choriocarcinoma, lung) prone to bleed.
• Coagulopathies: Anticoagulants (warfarin, DOACs), antiplatelets, thrombocytopenia, haemophilia, liver disease.
• Venous sinus thrombosis: Back-pressure haemorrhage → paradoxically requires anticoagulation.

🌍 Epidemiology

• More common in Afro-Caribbean, South-East Asian, and Japanese populations.
• Strong association with hypertension prevalence and genetic predisposition (amyloid angiopathy).

🧾 Causes by Age Group

• 🧓 Elderly: Hypertension, cerebral amyloid angiopathy.
• 👩 Younger adults: AVMs, aneurysms, cavernomas, coagulopathies.
• 💊 Any age: Anticoagulation therapy, illicit drugs (cocaine, amphetamines).

🧭 Types by Anatomy

• 🧠 Lobar: Cortex ± subcortical white matter.
• ⚫ Deep: Putaminal, thalamic, caudate, basal ganglia.
• 🧩 Brainstem: Pontine haemorrhage → sudden coma, pinpoint pupils.
• 🌀 Cerebellar: Ataxia, vertigo; large bleeds (>3 cm) may need evacuation.
• 💥 Subarachnoid haemorrhage: Usually aneurysmal.

📸 Example Imaging

CT and MRI examples of haemorrhagic stroke:

🩺 Clinical Presentation

• 🧨 Sudden severe headache, vomiting, reduced consciousness.
• 🧑‍⚕️ Focal neurology: hemiparesis, hemisensory loss, aphasia, neglect, visual field deficits.
• 🌀 Cerebellar bleeds: vertigo, nausea, truncal ataxia, nystagmus.
• 🟣 Brainstem bleeds: coma, quadriplegia, miosis, “locked-in” syndrome.
• 🔦 SAH: Thunderclap headache, collapse, meningism, reduced GCS.

⚠️ Complications

• Intraventricular extension → acute deterioration, coma.
• Hydrocephalus from ventricular obstruction.
• Cerebral oedema, raised ICP, herniation (coning).
• Seizures (early or delayed).
• Rebleeding, especially in aneurysmal SAH and AVM.

🚩 Red Flags for Secondary Causes

• Age <50.
• No history of hypertension.
• Recurrent or atypical bleeds.
• Lobar location (esp. with soft tissue swelling or fracture → trauma vs primary bleed).
• Family history or features of inherited vascular syndromes (HHT).

🔍 Investigations

• 🩸 Bloods: FBC, U&E, LFT, glucose, coagulation, ESR/CRP.
• 🖼️ Non-contrast CT: First-line, detects haematoma, intraventricular blood, hydrocephalus.
• 🧲 MRI: Detects microbleeds, chronic haemosiderin, cavernomas (SWI/GRE).
• 📡 MRA/CTA: Aneurysms, AVMs, dissections.
• 🩻 MRV: Suspected venous sinus thrombosis.
• 📌 DSA: Gold standard for vascular malformations; small stroke risk.
• ❤️ Echocardiography: Endocarditis, embolic source.
• 💉 LP: For SAH if CT normal but suspicion high.

📊 Prognostic Scoring (ICH Score)

• GCS: 3–4 (+2), 5–12 (+1), 13–15 (0).
• Age ≥80: +1.
• Volume >30 ml: +1.
• Intraventricular haemorrhage: +1.
• Infratentorial location: +1.

➡️ Higher total = worse prognosis. 0 = 0%, 1 = 13%, 2 = 26%, 3 = 72%, 4 = 97%, 5 = 100% 30-day mortality.

⚖️ Management

• 🛑 Immediate: ABC, airway support, early CT, correct coagulopathy, cautious BP lowering, neurosurgical referral.
• 💊 Reverse anticoagulation: Warfarin INR>1.4 → Vit K + PCC (Octaplex). Stop DOAC/antiplatelets. Avoid platelets (PATCH trial).
• 📉 Blood pressure: Reduce to <160 systolic with IV agents (e.g. labetalol). Avoid hypoperfusion.
• 🧑‍⚕️ Neurosurgery: Consider clot evacuation, especially cerebellar bleeds >3 cm or deteriorating GCS. EVD for hydrocephalus.
• 💉 Seizure control: IV phenytoin/levetiracetam if seizures.
• 🧑‍🦽 Rehabilitation: MDT stroke/ICU team for survivors.
• ❌ Avoid: Routine mannitol (except bridging), steroids (harmful), unnecessary statin withdrawal without review.

📉 Prognosis

• Large bleeds, IVH, infratentorial location, and advanced age = worse outcomes.
• Many survivors are left with major neurological deficits.

💡 Exam Pearl: Intracerebral haemorrhage = sudden headache + neuro deficit + ↓ consciousness. ➡️ Early non-contrast CT is essential - clinical features alone cannot distinguish from ischaemic stroke.