Review Question - QID 105006

The patient has an abrupt onset of acute right-sided facial and limb weakness and hyperdensity on non-contrast CT of the head, consistent with acute hemorrhagic stroke.

Acute stroke can be divided into ischemic (e.g. thrombotic, embolic) and hemorrhagic etiologies. The strongest risk factor for both ischemic and hemorrhagic stroke is hypertension. Both ischemic and hemorrhagic stroke typically present with the abrupt onset of neurologic deficits such as facial or limb weakness, as in this patient. Initial work-up of a patient with concern for stroke begins with a non-contrast head CT in order to rule out hemorrhage before consideration of intravenous tissue plasminogen activator (tPA) therapy, as distinction between ischemic and hemorrhagic strokes can be difficult based on symptoms alone. If hemorrhage is identified, tPA is contraindicated. If an ischemic stroke is suspected clinically and CT is negative for evidence of a hemorrhagic stroke, the recommended treatment is intravenous tPA if the presentation is within 3-4.5 hours of symptom onset. Those with acute hemorrhagic stroke identified on initial non-contrast CT scan of the head are managed with reversal of anticoagulation and blood pressure control as needed, with or without osmotic therapy (e.g. mannitol, hypertonic saline) or emergent neurosurgical intervention. Management is dependent on many factors such as the size of hemorrhage, severity of neurologic deficits and likelihood of recovery with intervention.

Unnithan et. al review the clinical manifestations, diagnosis and management of hemorrhagic stroke. They note that diagnosis is made with initial non-contrast CT scan of the head, and discuss medical and surgical management.

Figure A shows characteristic findings of acute hemorrhagic stroke on a non-contrast CT scan of the head. Note the hyper-dense are representing accumulation of blood

Illustration A displays a hypodense area on non-contrast CT scan of the head, consistent with ischemic stroke, for comparison.

Incorrect Answers:
Answer 2: Acute ischemic stroke typically presents with new-onset neurologic deficits similar to this patient’s. However, initial non-contrast CT scan of the head showing an area of hyperdensity is much more suggestive of hemorrhage rather than an ischemic etiology.

Answer 3: Glioblastoma multiforme may present with a mass on brain imaging, and may cause intracerebral hemorrhage as a result of tumor necrosis. However, it typically crosses the cerebral hemispheres, and would not appear hyperdense on non-contrast CT. Furthermore, a prior history of headaches, nausea or vomiting over the preceding weeks or months would be expected.

Answer 4: Partial seizure may occasionally present with residual neurologic deficits (e.g. Todd paralysis). However, non-contrast CT scan of the head in this case would be normal and would not demonstrate an area of hyperdensity.

Answer 5: Subdural hematoma is common in the setting of trauma in the elderly. It typically presents on non-contrast CT scan of the head as a crescent shaped hemorrhage between the brain and the skull. This patient’s hemorrhage is intracerebral.

Bullet Summary:
Acute hemorrhagic stroke presents with the abrupt onset of neurologic deficits and is characterized on non-contrast CT scan of the head by an area of hyperdensity.