Pathophysiology & Risk Factors

A ruptured cerebral vessel bleeds within or around the brain, compressing neural tissue and raising intracranial pressure. Intracerebral hemorrhage (ICH) bleeds into brain parenchyma; subarachnoid hemorrhage (SAH) bleeds into the space between arachnoid and pia, classically from a ruptured aneurysm. This is NOT the stroke treated with tPA.

Hemorrhagic vs Ischemic Stroke

HemorrhagicIschemic

CauseVessel rupture / bleed (uncontrolled HTN, aneurysm, AVM)Clot occluding a vessel

HallmarkSudden 'worst headache of my life', rapid LOC declineFocal deficits; CT may be normal early

Noncontrast CTHyperdense (bright white) acute bloodHypodense or normal early

TreatmentLower BP, reverse anticoagulation, surgical evacuation; NO tPAtPA / thrombectomy; permissive hypertension

Hemorrhagic

Cause: Vessel rupture / bleed (uncontrolled HTN, aneurysm, AVM)
Hallmark: Sudden 'worst headache of my life', rapid LOC decline
Noncontrast CT: Hyperdense (bright white) acute blood
Treatment: Lower BP, reverse anticoagulation, surgical evacuation; NO tPA

Ischemic

Cause: Clot occluding a vessel
Hallmark: Focal deficits; CT may be normal early
Noncontrast CT: Hypodense or normal early
Treatment: tPA / thrombectomy; permissive hypertension

Signs & Symptoms

EarlyProgresses →

Worst headache of my life Hallmark

thunderclap, maximal at onset

Vomiting

Severely elevated blood pressure

prominent in ICH

Nuchal rigidity

meningeal irritation in SAH

Photophobia

SAH meningismus

Seizure at onset

cortical irritation from blood

Late / Severe

Rapid decline in consciousness Hallmark

rising ICP from active bleed

Other findings

Focal neurologic deficits

arm drift, slurred speech

Diagnostics & Labs

Diagnostic

Noncontrast head CT Hallmark

first-line; acute blood is hyperdense (bright white)

Coagulation studies

PT, INR, aPTT to guide reversal

Monitor

Glasgow Coma Scale

trend q1-2h

Serial neuro checks

Interventions & Priorities

Secure the airway

intubate if GCS 8 or below

Lower systolic blood pressure

target SBP below 140 mmHg in ICH

Reverse anticoagulation

concurrent with BP control; limits hematoma expansion

Elevate head of bed 30 degrees

midline neutral; promotes venous drainage

Avoid Valsalva

treat vomiting, prevent ICP spikes

Seizure precautions

Quiet, dimly lit environment

Neurosurgical consultation

for hematoma evacuation or aneurysm repair

Treatments & Medications

Nicardipine IV

titratable BP control

Labetalol IV

alternative IV antihypertensive

Nimodipine

prevents/treats SAH cerebral vasospasm

Vitamin K plus PCC

reverses warfarin

Mannitol

osmotic therapy for refractory ICP

Aneurysm clipping or coiling

secures ruptured SAH aneurysm

tPAHold

ABSOLUTELY contraindicated; worsens bleed

AnticoagulantsHold

contraindicated; reverse if on board

AntiplateletsHold

contraindicated

Complications

Increased intracranial pressure

Cerebral herniation

Hematoma expansion

primary determinant of mortality

Cerebral vasospasm

peaks SAH days 4-14

Rebleeding

Report Nowescalate immediately

Cushing's triad Hallmark

widening pulse pressure, bradycardia, irregular respirations = rising ICP

Declining level of consciousness

falling GCS signals expanding bleed or herniation

Signs of rebleed

sudden worsening headache or new deficit

New focal deficit days 4-14 post-SAH

cerebral vasospasm; resume nimodipine + volume expansion

Pupillary changes

fixed or unequal pupils = herniation

Clinical Pearl

Bright white on CT, bright red alert: no tPA, no anticoagulants, reverse what's on board, and control that blood pressure before the bleed expands.

Hemorrhagic Stroke