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Source: Fagan S, Hess D. Hemorrhagic stroke. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. Accessed February 23, 2019.


  • Hemorrhagic stroke


  • Hemorrhagic strokes include subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH).

    • SAH occurs when blood enters the subarachnoid space due to trauma, rupture of an intracranial aneurysm or rupture of an arteriovenous malformation (AVM).

    • ICH occurs when blood vessel ruptures within the brain parenchyma, resulting in a hematoma.


  • 38% experience dramatic hemorrhage expansion occurs >3 hours after onset of symptoms.

  • Highest mortality seen in

    • GCS of 3–4

    • ICH volume >30 mL

    • Intraventricular extension

    • Brain stem involvement

    • >80 years of age

  • Presence of blood in the brain parenchyma causes mechanical compression of tissue and activation of inflammation and neurotoxins.


  • Stroke is the leading cause of adult disability.

  • The annual cost of stroke in the United States is estimated to be $33.6 billion.

  • African Americans are twice as likely to have a stroke than whites.

  • Case fatality due to hemorrhagic stroke has not declined in the past decade.


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Signs Symptoms
  • Multiple signs of neurologic dysfunction

  • Hemiparesis or monoparesis

  • Patients with vertigo and double vision are likely due to posterior circulation involvement

  • Aphasia—common with anterior circulation strokes

  • Dysarthria

  • Visual field defects

  • Altered level of consciousness

  • Weakness on one of the body

  • Inability to speak

  • Loss of vision

  • Vertigo

  • Falling

  • Very severe headache (hemorrhagic)


  • CT scan of the head (hyperintensity [white] in the area of hemorrhage)


  • Reduce ongoing neurologic injury.

  • Decrease mortality and long-term disability.

  • Prevent complications secondary to immobility and neurologic dysfunction.

  • Prevent stroke recurrence.


  • Early treatment for ICH with BP between 150 and 220 mm Hg systolic to achieve BP <140 mm Hg systolic has been shown to be safe and improve functional outcomes.

  • Prevent worsening of patient state.

  • Minimize complications.


  • SAH due to ruptured intracranial aneurysm or AVM

    • Surgical intervention to either clip or ablate the vascular abnormality

  • Primary ICH

    • Surgical evacuation may benefit in patients with intermediate hemorrhage volume of 20–50 mL.

    • External ventricular drain (EVD) for hydrocephalus and subsequent monitoring


  • No standard pharmacologic strategies for treating ICH

  • ICH due to an oral anticoagulant

    • Reversal of anticoagulation to prevent expansion and allow surgical intervention with

      • IV vitamin K

      • Fresh frozen plasma (FFP)

      • Hemostatic agents (PCC or factor VIIa)

    • Warfarin associated ICH ...

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