Intracerebral%20hemorrhage Diagnosis

• Assess presenting symptoms and associated activities at onset
• Determine time of stroke onset and age

• Vital signs
• General examination of the head, heart, lungs, abdomen and extremities
• Brief but thorough neurologic exam [eg National Institute of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS)]

• The earlier the time from onset of neurological symptoms to initial neuroimage, the more likely succeeding neuroimages will show hematoma expansion
• Hematoma expansion is predictive of clinical deterioration, and increased morbidity and mortality

Plain Cranial Computed Tomography (CT) Scan and Contrast-Enhanced Computed Tomography (CT) Scan

• CT scan differentiates ischemic stroke from intracerebral hemorrhage (ICH)
  • Scan will also show size, location and volume of hemorrhage
  • ICH volume >60 mL has exponential risk with mortality
  • May reveal structural abnormalities (eg aneurysms, brain tumors) which may have caused ICH, or structural complications (eg herniation, hydrocephalus, intraventricular hemorrhage)
  • Contrast-enhanced CT scan is useful in identifying patients at high risk of hematoma expansion

Cranial Magnetic Resonance Imaging (MRI)

• Equivalent to CT scan in determining the presence, size, location, and progression of acute ICH
• Superior at detecting underlying structural lesions or tumor, delineating the amount of perihematomal edema and herniation and multiple old hemorrhages or microbleeds that suggest amyloid angiopathy
• Used to check venous thrombosis, hemorrhages in high convexity, often bilateral and substantial edema

Angiography

• CT angiography is useful in detecting hematoma expansion or spot sign (ie contrast extravasation from active bleeding)
• Consider for all patients without clear cause of hemorrhage who are surgical candidates
  • Eg young, normotensive patients who are clinically stable
  • Useful in diagnosing secondary causes of ICH (eg aneurysm, arteriovenous malformation, venous sinus thrombosis, arteriovenous dural fistulae, vasculitis)
• Angiography not required in older hypertensive patients who have hemorrhage in basal ganglia, cerebellum, thalamus, or brain stem and in whom CT does not show structural lesion
•  Patient’s clinical state and neurologist/neurosurgeon’s discretion will determine the urgency and timing of angiography

• Complete blood count (CBC), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (aPTT), electrolytes, blood urea nitrogen (BUN), creatinine, glucose
• Urinalysis
• Electrocardiogram (ECG), chest X-ray
• Toxicology screen to rule out illicit drug use (eg cocaine, methamphetamine)