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The Rational Clinical Examination | Clinician's Corner

Does This Patient Have a Hemorrhagic Stroke?  Clinical Findings Distinguishing Hemorrhagic Stroke From Ischemic Stroke

Shauna Runchey, MD, MPH; Steven McGee, MD
JAMA. 2010;303(22):2280-2286. doi:10.1001/jama.2010.754.
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Published online

Context The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed.

Objective To determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke.

Data Sources MEDLINE and EMBASE searches of English-language articles published from January 1966 to April 2010.

Study Selection Prospective studies of adult patients with stroke that compared initial clinical findings with accepted diagnostic standards of hemorrhagic stroke (computed tomography or autopsy).

Data Extraction Both authors independently appraised study quality and extracted relevant data.

Data Synthesis Nineteen prospective studies meeting inclusion criteria were identified (N = 6438 patients; n = 1528 [24%] with hemorrhage stroke). Several findings significantly increase the probability of hemorrhagic stroke: coma (likelihood ratio [LR], 6.2; 95% confidence interval [CI], 3.2-12), neck stiffness (LR, 5.0; 95% CI, 1.9-12.8), seizures accompanying the neurologic deficit (LR, 4.7; 95% CI, 1.6-14), diastolic blood pressure greater than 110 mm Hg (LR, 4.3; 95% CI, 1.4-14), vomiting (LR, 3.0; 95% CI, 1.7-5.5), and headache (LR, 2.9; 95% CI, 1.7-4.8). Other findings decrease the probability of hemorrhage: cervical bruit (LR, 0.12; 95% CI, 0.03-0.47) and prior transient ischemic attack (LR, 0.34; 95% CI, 0.18-0.65). A Siriraj score greater than 1 increases the probability of hemorrhage (LR, 5.7; 95% CI, 4.4-7.4) while a score lower than −1 decreases the probability (LR, 0.29; 95% CI, 0.23-0.37). Nonetheless, many patients with stroke lack any diagnostic finding, and 20% have Siriraj scores between 1 and −1, which are diagnostically unhelpful (LR, 0.94; 95% CI, 0.77-1.1).

Conclusion In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.

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Figure. Explanation of Additional Symptoms of Intracerebral Hemorrhage
Graphic Jump Location

In the top panel, a small hemorrhage in the right basal ganglia causes left hemiparesis and a clinical presentation indistinguishable from ischemic stroke. As intracerebral bleeding continues (middle panel), expansion of the hemorrhage exerts a mass effect on the brain, increasing intracranial pressure and causing a midline shift. Clinical findings characteristic of hemorrhagic stroke manifest, such as progressive neurological deficits, headache, and vomiting. Eventually, blood may dissect into the ventricles and extend into the subarachnoid space via the median and lateral apertures of the fourth ventricle (bottom panel), leading to neck stiffness. In severe hemorrhagic stroke, intracerebral expansion of the hemorrhage may result in coma from bilateral cerebral dysfunction or uncal herniation.

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