Acute haemorrhagic stroke.

OBJECTIVE To review the management and some of the recent advances in acute haemorrhagic stroke. DATA SOURCES Articles and published reviews on acute haemorrhagic stroke. SUMMARY OF REVIEW Hypertensive intracerebral haemorrhage or subarachnoid haemorrhage (SAH) from a ruptured intracranial saccular aneurysm are the commonest causes for an acute haemorrhagic stroke. Both lesions are often clinically characterised by a sudden severe headache and vomiting with the remaining neurological features dependent on the site of the lesion. The diagnosis requires an urgent non-contrast cerebral computed tomography (CT) scan and a lumbar puncture if the CT scan fails to demonstrate intracranial blood. Treatment of both intracerebral haemorrhage and SAH includes resuscitation (e.g. cardiovascular and respiratory support) and preventative therapy (e.g. maintaining hydration and nutrition, and preventing aspiration and pressure sores, etc). Further management of an intracerebral haemorrhage by removing the clot is only beneficial if it is near the surface (although stereotactic catheter insertion and infusion of thrombolytics have been used with variable success with deeper haematomata) and if there are signs of intracerebral shift or compression of vital structures (e.g. cerebellar haematoma). Management of SAH still requires nimodipine and early angiography with surgery to reduce the incidence of cerebral vasospasm and rebleeding, respectively. While intravascular techniques using the Guglielmi detachable coil have improved the outcome in surgically inaccessible (and accessible) aneurysms, management of resistant cerebral vasospasm using 'triple H' therapy (i.e. hypertension, hypervolaemia and haemodilution), intraarterial papaverine, angioplasty, and intrathecal tPA, have not been uniformly successful. CONCLUSIONS Acute haemorrhagic stroke requires an urgent non-contrast cerebral CT scan for diagnosis. Treatment of an intracerebral haematoma requires evacuation of the clot if accessible and if it is causing an intracerebral shift or compression of vital structures. Nimodipine and urgent surgery to reduce the incidence of cerebral vasospasm and rebleeding, respectively, are standard for the management of a patient with a SAH. While recent advances in intravascular techniques using the Guglielmi detachable coil hold promise, successful management of resistant cerebral vasospasm remains elusive.