Fast Five Quiz: Test Your Knowledge on Key Aspects of Hemorrhagic Stroke

Amy Kao, MD

Disclosures

May 10, 2018

The most common cause of atraumatic hemorrhage into the subarachnoid space is rupture of an intracranial aneurysm. Aneurysms are focal dilatations of arteries, with the most frequently encountered intracranial type being the berry (saccular) aneurysm. Less commonly, aneurysms may be related to altered hemodynamics associated with arteriovenous malformations (AVMs), collagen vascular disease, polycystic kidney disease, septic emboli, and neoplasms. Nonaneurysmal perimesencephalic subarachnoid hemorrhage may also be seen. This phenomenon is thought to arise from capillary or venous rupture. It has a less severe clinical course and, in general, a better prognosis.

The risk for hemorrhagic stroke is increased with the following factors:

  • Advanced age

  • Hypertension (as many as 60% of cases)

  • History of stroke

  • Alcohol abuse

  • Use of illicit drugs (eg, cocaine, other sympathomimetic drugs)

Causes of hemorrhagic stroke include the following:

  • Hypertension

  • Cerebral amyloidosis

  • Coagulopathies

  • Anticoagulant therapy

  • Thrombolytic therapy for acute myocardial infarction (MI) or acute ischemic stroke (can cause iatrogenic hemorrhagic transformation)

  • AVM, aneurysms, and other vascular malformations (venous and cavernous angiomas)

  • Vasculitis

  • Intracranial neoplasm

The most common etiology of primary hemorrhagic stroke (intracerebral hemorrhage) is hypertension. At least two thirds of patients with primary intraparenchymal hemorrhage are reported to have pre-existing or newly diagnosed hypertension. Coagulopathies may be acquired or inherited. Liver disease can result in a bleeding diathesis. Inherited coagulation disorders such as factor VII, VIII, IX, X, and XIII deficiency can predispose to excessive bleeding, and intracranial hemorrhage has been seen in all of these disorders.

Hemorrhagic transformation represents the conversion of a bland infarction into an area of hemorrhage. Proposed mechanisms for hemorrhagic transformation include reperfusion of ischemically injured tissue, either from recanalization of an occluded vessel or from collateral blood supply to the ischemic territory or disruption of the blood-brain barrier. Hemorrhagic transformation of an ischemic infarct occurs within 2-14 days postictus, usually within the first week. It is more commonly seen following cardioembolic strokes and is more likely with larger infarct size.

For more on the etiology of hemorrhagic stroke, read here.

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