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Imaging of Hemorrhagic Stroke

Hakimi, Ryan DO, MS; Garg, Ankur MD

CONTINUUM: Lifelong Learning in Neurology: October 2016 - Volume 22 - Issue 5, Neuroimaging - p 1424–1450
doi: 10.1212/CON.0000000000000377
Review Articles

ABSTRACT Purpose of Review: Hemorrhagic stroke comprises approximately 15% to 20% of all strokes. This article provides readers with an understanding of the indications and significance of various neuroimaging techniques available for patients presenting with hemorrhagic strokes of distinct causes.

Recent Findings: The most common initial neuroimaging study is a noncontrast head CT, which allows for the identification of hemorrhage. Once an intracranial hemorrhage has been identified, the pattern of blood and the patient’s medical history, neurologic examination, and laboratory studies lead the practitioner to pursue further neuroimaging studies to guide the medical, surgical, and interventional management. Given that hemorrhagic stroke constitutes a heterogeneous collection of diagnoses, the subsequent neuroimaging pathway necessary to better evaluate and care for these patients is variable based on the etiology.

With an increasing incidence and prevalence of atrial fibrillation associated with the aging population and the introduction of three new direct factor Xa inhibitors and one direct thrombin inhibitor to complement vitamin K antagonists, oral anticoagulant use continues to increase. Patients on oral anticoagulants have a sevenfold to tenfold increased risk for intracerebral hemorrhage (ICH). Furthermore, patients who have an ICH associated with oral anticoagulant use have a higher mortality rate than those with primary ICH. Despite the reduced incidence of hypertension-related ICH over the past decade, it is expected that the incidence of ICH will continue to increase.

Summary: Neuroimaging studies are integral to the identification of hemorrhagic stroke, determination of the underlying etiology, prevention of hematoma expansion, treatment of acute complications, and treatment of the underlying etiology, if indicated. Neuroimaging is essential for prognostication and thus directly impacts patient care.

Address correspondence to Dr Ryan Hakimi, University of South Carolina-Greenville, Greenville Health System Neuroscience Associates, 200 Patewood Dr, #350, Greenville, SC 29615,

Relationship Disclosure: Dr Hakimi has served on the board of directors and annual program committee of the American Society of Neuroimaging, on the editorial boards of the International Journal of Neurology and Neurotherapy and the International Journal of Neural Science and Brain Research, and on the annual program committee and as cochair of the fundraising committee of the Neurocritical Care Society. Dr Garg serves on the membership committee of the Society of Vascular and Interventional Neurology.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Hakimi and Garg report no disclosures.

© 2016 American Academy of Neurology
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