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Hemorrhagic Stroke Clinical Presentation

Hemorrhagic Stroke Clinical Presentation

Author: David S Liebeskind, MD; Chief Editor: Rick Kulkarni, MD more... Updated: Mar 8, 2013

History
Obtaining an adequate history includes determining the onset and progression of symptoms, as well as assessing for risk factors and possible causative events. Such risk factors include the following: Previous transient ischemic attack (TIA) and stroke Hypertension Diabetes Smoking Arrhythmia and valvular disease Illicit drug use Use of anticoagulants Risk factors for thrombosis A history of trauma, even if minor, may be important, as extracranial arterial dissections can result in ischemic stroke.

Hemorrhagic versus ischemic stroke

Symptoms alone are not specific enough to distinguish ischemic from hemorrhagic stroke. However, generalized symptoms, including nausea, vomiting, and headache, as well as an altered level of consciousness, may indicate increased intracranial pressure and are more common with hemorrhagic strokes and large ischemic strokes. Seizures are more common in hemorrhagic stroke than in the ischemic kind. Seizures occur in up to 28% of hemorrhagic strokes, generally at the onset of the intracerebral hemorrhage or within the first 24 hours.

Focal neurologic deficits

The neurologic deficits reflect the area of the brain typically involved, and stroke syndromes for specific vascular lesions have been described. Focal symptoms of stroke include the following: Weakness or paresis that may affect a single extremity, one half of the body, or all 4 extremities Facial droop Monocular or binocular blindness Blurred vision or visual field deficits Dysarthria and trouble understanding speech Vertigo or ataxia Aphasia

Subarachnoid hemorrhage
Symptoms of subarachnoid hemorrhage may include the following: Sudden onset of severe headache Signs of meningismus with nuchal rigidity Photophobia and pain with eye movements
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Hemorrhagic Stroke Clinical Presentation

Nausea and vomiting Syncope - Prolonged or atypical The most common clinical scoring systems for grading aneurysmal subarachnoid hemorrhage are the Hunt and Hess grading scheme and the World Federation of Neurosurgeons (WFNS) grading scheme, which incorporates the Glasgow Coma Scale. The Fisher Scale incorporates findings from noncontrast computed tomography (NCCT) scans.

Physical Examination
The assessment in patients with possible hemorrhagic stroke includes vital signs; a general physical examination that focuses on the head, heart, lungs, abdomen, and extremities; and a thorough but expeditious neurologic examination.[28] However, intracerebral hemorrhage may be clinically indistinguishable from ischemic stroke. (Though stroke is less common in children, the clinical presentation is similar.) Hypertension (particularly systolic blood pressure [BP] greater than 220 mm Hg) is commonly a prominent finding in hemorrhagic stroke. Higher initial BP is associated with early neurologic deterioration, as is fever.[28] An acute onset of neurologic deficit, altered level of consciousness/mental status, or coma is more common with hemorrhagic stroke than with ischemic stroke. Often, this is caused by increased intracranial pressure. Meningismus may result from blood in the subarachnoid space. Examination results can be quantified using various scoring systems. These include the Glasgow Coma Scale (GCS), the Intracerebral Hemorrhage Score (which incorporates the GCS; see Prognosis), and the National Institutes of Health Stroke Scale.

Focal neurologic deficits

The type of deficit depends upon the area of brain involved. If the dominant hemisphere (usually the left) is involved, a syndrome consisting of the following may result: Right hemiparesis Right hemisensory loss Left gaze preference Right visual field cut Aphasia Neglect (atypical) If the nondominant (usually the right) hemisphere is involved, a syndrome consisting of the following may result: Left hemiparesis Left hemisensory loss Right gaze preference Left visual field cut Nondominant hemisphere syndrome may also result in neglect when the patient has left-sided hemi-inattention and ignores the left side. If the cerebellum is involved, the patient is at high risk for herniation and brainstem compression. Herniation may cause a rapid decrease in the level of consciousness and may result in apnea or death. Specific brain sites and associated deficits involved in hemorrhagic stroke include the following: Putamen - Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, aphasia, neglect, or apraxia Thalamus - Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia, miosis, aphasia, or confusion Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, abulia, aphasia, neglect, or apraxia
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Caudate nucleus - Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion Brainstem - Quadriparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular bobbing, miosis, or autonomic instability Cerebellum Ipsilateral ataxia, facial weakness, sensory loss; gaze paresis, skew deviation, miosis, or decreased level of consciousness Other signs of cerebellar or brainstem involvement include the following: Gait or limb ataxia Vertigo or tinnitus Nausea and vomiting Hemiparesis or quadriparesis Hemisensory loss or sensory loss of all 4 limbs Eye movement abnormalities resulting in diplopia or nystagmus Oropharyngeal weakness or dysphagia Crossed signs (ipsilateral face and contralateral body) Many other stroke syndromes are associated with intracerebral hemorrhage, ranging from mild headache to neurologic devastation. At times, a cerebral hemorrhage may present as a new-onset seizure.

Contributor Information and Disclosures

Author David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association Disclosure: Nothing to disclose. Chief Editor Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: WebMD Salary Employment Additional Contributors J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

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Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association Disclosure: Nothing to disclose. Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Helmi L Lutsep, MD Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership Denise Nassisi, MD Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center Denise Nassisi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Jeffrey L Saver, MD, FAHA, FAAN Professor of Neurology, Director, UCLA Stroke Center, University of California, Los Angeles, David Geffen School of Medicine Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, and National Stroke Association Disclosure: University of California The University of California Regents receive funds for consulting services on clinical trial design provided to Telecris, Ev3, and CoAxia. Consulting Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment

References
1. Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol. Jan 2003;2(1):43-53. [Medline]. 2. [Guideline] Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation. Oct 16 2007;116(16):e391-413. [Medline]. 3. Yock-Corrales A, Mackay MT, Mosley I, Maixner W, Babl FE. Acute childhood arterial ischemic and hemorrhagic stroke in the emergency department. Ann Emerg Med. Aug 2011;58(2):156-63. [Medline].
emedicine.medscape.com/article/1916662-clinical#showall 4/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

4. Kim EY, Na DG, Kim SS, Lee KH, Ryoo JW, Kim HK. Prediction of hemorrhagic transformation in acute ischemic stroke: role of diffusion-weighted imaging and early parenchymal enhancement. AJNR Am J Neuroradiol. May 2005;26(5):1050-5. [Medline]. 5. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. Jan 3 2012;125(1):e2e220. [Medline]. 6. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Strok e. Jan 1993;24(1):35-41. [Medline]. 7. Thrift AG, Dewey HM, Macdonell RA, McNeil JJ, Donnan GA. Incidence of the major stroke subtypes: initial findings from the North East Melbourne stroke incidence study (NEMESIS). Strok e. Aug 2001;32(8):1732-8. [Medline]. 8. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. May 10 2008;371(9624):1612-23. [Medline]. 9. Mullins ME, Lev MH, Schellingerhout D, Gonzalez RG, Schaefer PW. Intracranial hemorrhage complicating acute stroke: how common is hemorrhagic stroke on initial head CT scan and how often is initial clinical diagnosis of acute stroke eventually confirmed?. AJNR Am J Neuroradiol. Oct 2005;26(9):2207-12. [Medline]. 10. Nighoghossian N, Hermier M, Adeleine P, Blanc-Lasserre K, Derex L, Honnorat J, et al. Old microbleeds are a potential risk factor for cerebral bleeding after ischemic stroke: a gradient-echo T2*-weighted brain MRI study. Strok e. Mar 2002;33(3):735-42. [Medline]. 11. Auer RN, Sutherland GR. Primary intracerebral hemorrhage: pathophysiology. Can J Neurol Sci. Dec 2005;32 Suppl 2:S3-12. [Medline]. 12. Thrift AG, Donnan GA, McNeil JJ. Epidemiology of intracerebral hemorrhage. Epidemiol Rev. 1995;17(2):361-81. [Medline]. 13. Gokaslan ZL, Narayan RK. Intracranial hemorrhage in the hypertensive patient. Neuroimaging Clin N Am. 1992;Vol. 2:171-86. 14. International Warfarin Pharmacogenetics Consortium, Klein TE, Altman RB, et al. Estimation of the warfarin dose with clinical and pharmacogenetic data. N Engl J Med. Feb 19 2009;360(8):753-64. [Medline]. [Full Text]. 15. Chapman AB, Rubinstein D, Hughes R, Stears JC, Earnest MP, Johnson AM, et al. Intracranial aneurysms in autosomal dominant polycystic kidney disease. N Engl J Med. Sep 24 1992;327(13):91620. [Medline]. 16. Regalado E, Medrek S, Tran-Fadulu V, et al. Autosomal dominant inheritance of a predisposition to thoracic aortic aneurysms and dissections and intracranial saccular aneurysms. Am J Med Genet A. Sep 2011;155A(9):2125-30. [Medline]. 17. Dubey N, Bakshi R, Wasay M, Dmochowski J. Early computed tomography hypodensity predicts hemorrhage after intravenous tissue plasminogen activator in acute ischemic stroke. J Neuroimaging. Apr 2001;11(2):184-8. [Medline]. 18. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. Dec 14 1995;333(24):1581-7. [Medline]. 19. Gonzlez RG. Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain". AJNR Am J Neuroradiol. Apr 2006;27(4):728-35. [Medline]. 20. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sep
emedicine.medscape.com/article/1916662-clinical#showall 5/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

2004;126(3 Suppl):483S-512S. [Medline]. 21. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet. May 3 1997;349(9061):1269-76. [Medline]. 22. Shiber JR, Fontane E, Adewale A. Stroke registry: hemorrhagic vs ischemic strokes. Am J Emerg Med. Mar 2010;28(3):331-3. [Medline]. 23. Flaherty ML, Woo D, Haverbusch M, Sekar P, Khoury J, Sauerbeck L, et al. Racial variations in location and risk of intracerebral hemorrhage. Strok e. May 2005;36(5):934-7. [Medline]. 24. Global Burden of Stroke. The Atlas of Heart Disease and Stroke. MacKay J, Mensah GA. World Health Organization. [Full Text]. 25. Sacco S, Marini C, Toni D, Olivieri L, Carolei A. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Strok e. 2009;40:394399. 26. Centers for Disease Control and Prevention (CDC. Prevalence of stroke--United States, 2005. MMWR Morb Mortal Wk ly Rep. May 18 2007;56(19):469-74. [Medline]. 27. Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Strok e. Apr 2001;32(4):891-7. [Medline]. [Full Text]. 28. [Guideline] Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Strok e. Sep 2010;41(9):2108-29. [Medline]. 29. Zhu XL, Chan MS, Poon WS. Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Strok e. Jul 1997;28(7):1406-9. [Medline]. 30. Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G. Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia. Oct 2002;43(10):1175-80. [Medline]. 31. Vespa PM, O'Phelan K, Shah M, Mirabelli J, Starkman S, Kidwell C, et al. Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology. May 13 2003;60(9):1441-6. [Medline]. 32. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Strok e. Jun 2012;43(6):1711-37. [Medline]. [Full Text]. 33. Misra UK, Kalita J, Ranjan P, Mandal SK. Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci. Jul 15 2005;234(1-2):41-5. [Medline]. 34. Avorn J, Kesselheim A. A hemorrhage of off-label use. Ann Intern Med. Apr 19 2011;154(8):566-7. [Medline]. 35. Yank V, Tuohy CV, Logan AC, et al. Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications. Ann Intern Med. Apr 19 2011;154(8):529-40. [Medline]. 36. Logan AC, Yank V, Stafford RS. Off-Label Use of Recombinant Factor VIIa in U.S. Hospitals: Analysis of Hospital Records. Ann Intern Med. Apr 19 2011;154(8):516-22. [Medline]. 37. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. May 15 2008;358(20):2127-37. [Medline]. 38. [Best Evidence] Diringer MN, Skolnick BE, Mayer SA, Steiner T, Davis SM, Brun NC, et al.
emedicine.medscape.com/article/1916662-clinical#showall 6/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

Thromboembolic events with recombinant activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Strok e. Jan 2010;41(1):48-53. [Medline]. 39. Sarode R, Matevosyan K, Bhagat R, Rutherford C, Madden C, Beshay JE. Rapid warfarin reversal: a 3factor prothrombin complex concentrate and recombinant factor VIIa cocktail for intracerebral hemorrhage. J Neurosurg. Mar 2012;116(3):491-7. [Medline]. 40. Lankiewicz MW, Hays J, Friedman KD, Tinkoff G, Blatt PM. Urgent reversal of warfarin with prothrombin complex concentrate. J Thromb Haemost. May 2006;4(5):967-70. [Medline]. 41. Huttner HB, Schellinger PD, Hartmann M, Khrmann M, Juettler E, Wikner J, et al. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Strok e. Jun 2006;37(6):1465-70. [Medline]. 42. Steiner T, Freiberger A, Griebe M, Hsing J, Ivandic B, Kollmar R, et al. International normalised ratio normalisation in patients with coumarin-related intracranial haemorrhages--the INCH trial: a randomised controlled multicentre trial to compare safety and preliminary efficacy of fresh frozen plasma and prothrombin complex--study design and protocol. Int J Strok e. Jun 2011;6(3):271-7. [Medline]. 43. [Best Evidence] Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. Jan 29-Feb 4 2005;365(9457):387-97. [Medline]. 44. Gregson BA, Broderick JP, Auer LM, Batjer H, Chen XC, Juvela S, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Strok e. Jun 2012;43(6):1496-504. [Medline]. [Full Text]. 45. Steiner T, Vincent C, Morris S, Davis S, Vallejo-Torres L, Christensen MC. Neurosurgical outcomes after intracerebral hemorrhage: results of the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). J Strok e Cerebrovasc Dis . Jul-Aug 2011;20(4):287-94. [Medline]. 46. Mendelow AD, Gregson BA, Mitchell PM, Murray GD, Rowan EN, Gholkar AR. Surgical trial in lobar intracerebral haemorrhage (STICH II) protocol. Trials . May 17 2011;12:124. [Medline]. [Full Text]. 47. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. Sep 3-9 2005;366(9488):809-17. [Medline]. 48. Byrne JV. The aneurysm "clip or coil" debate. Acta Neurochir (Wien). Feb 2006;148(2):115-20. [Medline]. 49. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg. Jan 2012;116(1):135-44. [Medline]. 50. Lanzino G. The Barrow Ruptured Aneurysm Trial. J Neurosurg. Jan 2012;116(1):133-4; discussion 134. [Medline]. 51. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. Jan 1968;28(1):14-20. [Medline]. 52. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. Jan 1980;6(1):1-9. [Medline]. 53. [Guideline] Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Strok e. Feb 2011;42(2):517-84. [Medline]. [Full Text]. 54. McKinney JS, Kostis WJ. Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31
emedicine.medscape.com/article/1916662-clinical#showall 7/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

randomized controlled trials. Strok e. Aug 2012;43(8):2149-56. [Medline]. 55. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-convertingenzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. Jan 20 2000;342(3):145-53. [Medline]. 56. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. Sep 29 2001;358(9287):1033-41. [Medline]. 57. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. Dec 18 2002;288(23):2981-97. [Medline]. 58. Dahlf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. Mar 23 2002;359(9311):995-1003. [Medline]. 59. Schrader J, Lders S, Kulschewski A, Hammersen F, Plate K, Berger J, et al. Morbidity and Mortality After Stroke, Eprosartan Compared with Nitrendipine for Secondary Prevention: principal results of a prospective randomized controlled study (MOSES). Strok e. Jun 2005;36(6):1218-26. [Medline]. 60. Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Cardiorespiratory fitness and the risk for stroke in men. Arch Intern Med. Jul 28 2003;163(14):1682-8. [Medline]. 61. Ahmed N, Nsman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Strok e. Jun 2000;31(6):1250-5. [Medline]. [Full Text]. 62. Aso K, Ogasawara K, Sasaki M, Kobayashi M, Suga Y, Chida K, et al. Preoperative cerebrovascular reactivity to acetazolamide measured by brain perfusion SPECT predicts development of cerebral ischemic lesions caused by microemboli during carotid endarterectomy. Eur J Nucl Med Mol Imaging. Feb 2009;36(2):294-301. [Medline]. 63. Becker H, Desch H, Hacker H, Pencz A. CT fogging effect with ischemic cerebral infarcts. Neuroradiology. Oct 31 1979;18(4):185-92. [Medline]. 64. Borisch I, Horn M, Butz B, Zorger N, Draganski B, Hoelscher T, et al. Preoperative evaluation of carotid artery stenosis: comparison of contrast-enhanced MR angiography and duplex sonography with digital subtraction angiography. AJNR Am J Neuroradiol. Jun-Jul 2003;24(6):1117-22. [Medline]. 65. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. Aug 2008;29(7):1409-13. [Medline]. 66. Bozzao L, Bastianello S, Fantozzi LM, Angeloni U, Argentino C, Fieschi C. Correlation of angiographic and sequential CT findings in patients with evolving cerebral infarction. AJNR Am J Neuroradiol. Nov-Dec 1989;10(6):1215-22. [Medline]. 67. Bozzao L, Fantozzi LM, Bastianello S, Bozzao A, Argentino C, Lenzi GL, et al. Ischaemic supratentorial stroke: angiographic findings in patients examined in the very early phase. J Neurol. Sep 1989;236(6):340-2. [Medline]. 68. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Strok e. Jul 1989;20(7):864-70. [Medline]. 69. Brown PB, Zwiebel WJ, Call GK. Degree of cervical carotid artery stenosis and hemispheric stroke: duplex US findings. Radiology. Feb 1989;170(2):541-3. [Medline]. 70. Burdette JH, Ricci PE, Petitti N, Elster AD. Cerebral infarction: time course of signal intensity changes on diffusion-weighted MR images. AJR Am J Roentgenol. Sep 1998;171(3):791-5. [Medline].
emedicine.medscape.com/article/1916662-clinical#showall 8/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

71. Carroll BA. Duplex sonography in patients with hemispheric symptoms. J Ultrasound Med. Oct 1989;8(10):535-40. [Medline]. 72. Chandra VR, Pandav R, Laxminarayan R, et al. Neurologic Disorders. In: Jamison DT, Measham AR, Breman JB, et al, eds. Disease Control Priorities in Developing Countries . 2nd ed. New York, NY: Oxford University Press and The World Bank; 2006:627-43. 73. Chappell FM, Wardlaw JM, Young GR, Gillard JH, Roditi GH, Yip B, et al. Carotid artery stenosis: accuracy of noninvasive tests--individual patient data meta-analysis. Radiology. May 2009;251(2):493-502. [Medline]. 74. de Virgilio C, Toosie K, Arnell T, Lewis RJ, Donayre CE, Baker JD, et al. Asymptomatic carotid artery stenosis screening in patients with lower extremity atherosclerosis: a prospective study. Ann Vasc Surg. Jul 1997;11(4):374-7. [Medline]. 75. Delgado AL, Jahromi B, Muller N, Farhat H, Salame J, Zauner A. Endovascular therapy of cerebral vasospasm: two year experience with angioplasty and/or intraarterial administration of nicardipine and verapamil. Acta Neurochir Suppl. 2008;104:347-51. 76. Eastwood JD, Lev MH, Azhari T, Lee TY, Barboriak DP, Delong DM, et al. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Radiology. Jan 2002;222(1):227-36. [Medline]. 77. Elster AD, Moody DM. Early cerebral infarction: gadopentetate dimeglumine enhancement. Radiology. Dec 1990;177(3):627-32. [Medline]. 78. Goldenberg G, Reisner T. Angiographic findings in relation to clinical course and results of computed tomography in cerebrovascular disease. Eur Neurol. 1983;22(2):124-30. [Medline]. 79. Gonzlez RG, Schaefer PW, Buonanno FS, Schwamm LH, Budzik RF, Rordorf G, et al. Diffusionweighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology. Jan 1999;210(1):155-62. [Medline]. 80. Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. Radiology. Nov 2003;229(2):340-6. [Medline]. 81. Grant EG, Duerinckx AJ, El Saden SM, Melany ML, Hathout GM, Zimmerman PT, et al. Ability to use duplex US to quantify internal carotid arterial stenoses: fact or fiction?. Radiology. Jan 2000;214(1):24752. [Medline]. 82. Karonen JO, Partanen PL, Vanninen RL, Vainio PA, Aronen HJ. Evolution of MR contrast enhancement patterns during the first week after acute ischemic stroke. AJNR Am J Neuroradiol. Jan 2001;22(1):10311. [Medline]. 83. Kucinski T, Vterlein O, Glauche V, Fiehler J, Klotz E, Eckert B, et al. Correlation of apparent diffusion coefficient and computed tomography density in acute ischemic stroke. Strok e. Jul 2002;33(7):1786-91. [Medline]. 84. Lyden PD, Zivin JA. Hemorrhagic transformation after cerebral ischemia: mechanisms and incidence. Cerebrovasc Brain Metab Rev. Spring 1993;5(1):1-16. [Medline]. 85. Marks MP. CT in ischemic stroke. Neuroimaging Clin N Am. Aug 1998;8(3):515-23. [Medline]. 86. Martin PJ, Enevoldson TP, Humphrey PR. Causes of ischaemic stroke in the young. Postgrad Med J . Jan 1997;73(855):8-16. [Medline]. [Full Text]. 87. Meerwaldt R, Slart RH, van Dam GM, Luijckx GJ, Tio RA, Zeebregts CJ. PET/SPECT imaging: from carotid vulnerability to brain viability. Eur J Radiol. Apr 2010;74(1):104-9. [Medline]. 88. Minematsu K, Li L, Fisher M, Sotak CH, Davis MA, Fiandaca MS. Diffusion-weighted magnetic resonance
emedicine.medscape.com/article/1916662-clinical#showall 9/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

imaging: rapid and quantitative detection of focal brain ischemia. Neurology. Jan 1992;42(1):235-40. [Medline]. 89. Nabavi DG, Cenic A, Craen RA, Gelb AW, Bennett JD, Kozak R, et al. CT assessment of cerebral perfusion: experimental validation and initial clinical experience. Radiology. Oct 1999;213(1):141-9. [Medline]. 90. Nishihara T, Nagata K, Tanaka S, Suzuki Y, Izumi M, Mochizuki Y, et al. Newly developed endoscopic instruments for the removal of intracerebral hematoma. Neurocrit Care. 2005;2(1):67-74. [Medline]. 91. Noguchi K, Ogawa T, Inugami A, Fujita H, Hatazawa J, Shimosegawa E, et al. MRI of acute cerebral infarction: a comparison of FLAIR and T2-weighted fast spin-echo imaging. Neuroradiology. Jun 1997;39(6):406-10. [Medline]. 92. Oliveira-Filho J, Silva SC, Trabuco CC, Pedreira BB, Sousa EU, Bacellar A. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology. Oct 28 2003;61(8):1047-51. [Medline]. 93. Oppenheim C, Logak M, Dormont D, Lehricy S, Mana R, Samson Y, et al. Diagnosis of acute ischaemic stroke with fluid-attenuated inversion recovery and diffusion-weighted sequences. Neuroradiology. Aug 2000;42(8):602-7. [Medline]. 94. Powers WJ, Grubb RL Jr, Darriet D, Raichle ME. Cerebral blood flow and cerebral metabolic rate of oxygen requirements for cerebral function and viability in humans. J Cereb Blood Flow Metab . Dec 1985;5(4):600-8. [Medline]. 95. Pressman BD, Tourje EJ, Thompson JR. An early sign of ischemic infarction: increased density in a cerebral artery. AJR Am J Roentgenol. 1987;149(3):583-6. 96. Saur D, Kucinski T, Grzyska U, Eckert B, Eggers C, Niesen W, et al. Sensitivity and interrater agreement of CT and diffusion-weighted MR imaging in hyperacute stroke. AJNR Am J Neuroradiol. May 2003;24(5):878-85. [Medline]. 97. Schaefer PW, Hassankhani A, Putman C, Sorensen AG, Schwamm L, Koroshetz W, et al. Characterization and evolution of diffusion MR imaging abnormalities in stroke patients undergoing intraarterial thrombolysis. AJNR Am J Neuroradiol. Jun-Jul 2004;25(6):951-7. [Medline]. 98. Schaefer PW, Roccatagliata L, Ledezma C, Hoh B, Schwamm LH, Koroshetz W, et al. First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol. Jan 2006;27(1):20-5. [Medline]. 99. Schramm P, Schellinger PD, Klotz E, Kallenberg K, Fiebach JB, Klkens S, et al. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusionweighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours' duration. Strok e. Jul 2004;35(7):1652-8. [Medline]. 100. Schuierer G, Huk W. The unilateral hyperdense middle cerebral artery: an early CT-sign of embolism or thrombosis. Neuroradiology. 1988;30(2):120-2. [Medline]. 101. Shetty SK, Lev MH. CT perfusion in acute stroke. Neuroimaging Clin N Am. Aug 2005;15(3):481-501, ix. [Medline]. 102. Skriver EB, Olsen TS. Transient disappearance of cerebral infarcts on CT scan, the so-called fogging effect. Neuroradiology. 1981;22(2):61-5. [Medline]. 103. Smith TP, Enterline DS. Endovascular treatment of cerebral vasospasm. J Vasc Interv Radiol. May 2000;11(5):547-59. [Medline]. 104. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Strok e. Apr 2008;39(4):1205-12. [Medline].
emedicine.medscape.com/article/1916662-clinical#showall 10/11

10/4/13

Hemorrhagic Stroke Clinical Presentation

105. Sorensen A, Copen W, Ostergaard L, Vainio PA, Aronen HJ. Hyperacute stroke: simultaneous measurement of relative cerebral blood volume, relative cerebral blood flow and mean tissue transit time. Radiology. 1999;210 (2):519-27. 106. Sorensen AG, Buonanno FS, Gonzalez RG, Schwamm LH, Lev MH, Huang-Hellinger FR, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology. May 1996;199(2):391-401. [Medline]. 107. Steiner T, Freiberger A, Griebe M, Hsing J, Ivandic B, Kollmar R, et al. International normalised ratio normalisation in patients with coumarin-related intracranial haemorrhages--the INCH trial: a randomised controlled multicentre trial to compare safety and preliminary efficacy of fresh frozen plasma and prothrombin complex--study design and protocol. Int J Strok e. Jun 2011;6(3):271-7. [Medline]. 108. Sunshine JL, Tarr RW, Lanzieri CF, Landis DM, Selman WR, Lewin JS. Hyperacute stroke: ultrafast MR imaging to triage patients prior to therapy. Radiology. Aug 1999;212(2):325-32. [Medline]. 109. Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F. Early CT finding in cerebral infarction: obscuration of the lentiform nucleus. Radiology. Aug 1988;168(2):463-7. [Medline]. 110. Torres-Mozqueda F, He J, Yeh IB, Schwamm LH, Lev MH, Schaefer PW, et al. An acute ischemic stroke classification instrument that includes CT or MR angiography: the Boston Acute Stroke Imaging Scale. AJNR Am J Neuroradiol. Jun 2008;29(6):1111-7. [Medline]. 111. Toyoda K, Ida M, Fukuda K. Fluid-attenuated inversion recovery intraarterial signal: an early sign of hyperacute cerebral ischemia. AJNR Am J Neuroradiol. Jun-Jul 2001;22(6):1021-9. [Medline]. 112. Truwit CL, Barkovich AJ, Gean-Marton A, Hibri N, Norman D. Loss of the insular ribbon: another early CT sign of acute middle cerebral artery infarction. Radiology. Sep 1990;176(3):801-6. [Medline]. 113. von Kummer R, Meyding-Lamad U, Forsting M, Rosin L, Rieke K, Hacke W, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol. Jan 1994;15(1):9-15; discussion 16-8. [Medline]. 114. Wetzel SG. Cerebral arteries and veins. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:381-441. 115. Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke severity with the NIH Stroke Scale. Strok e. Apr 2000;31(4):858-62. [Medline]. 116. Wintermark M, Maeder P, Thiran JP, Schnyder P, Meuli R. Quantitative assessment of regional cerebral blood flows by perfusion CT studies at low injection rates: a critical review of the underlying theoretical models. Eur Radiol. 2001;11(7):1220-30. [Medline]. 117. Wong GK, Siu DY, Ahuja AT, King AD, Yu SC, Zhu XL, et al. Comparisons of DSA and MR angiography with digital subtraction angiography in 151 patients with subacute spontaneous intracerebral hemorrhage. J Clin Neurosci. May 2010;17(5):601-5. [Medline]. 118. Woodcock RJ Jr, Short J, Do HM, Jensen ME, Kallmes DF. Imaging of acute subarachnoid hemorrhage with a fluid-attenuated inversion recovery sequence in an animal model: comparison with non-contrastenhanced CT. AJNR Am J Neuroradiol. Oct 2001;22(9):1698-703. [Medline]. 119. Zia E, Engstrm G, Svensson PJ, Norrving B, Pessah-Rasmussen H. Three-year survival and stroke recurrence rates in patients with primary intracerebral hemorrhage. Strok e. Nov 2009;40(11):3567-73. [Medline]. Medscape Reference 2011 WebMD, LLC

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