Etiologies

Hypertension

Bleeding disorders

Monoamine oxidase inhibitor (MAOI) hypertensive reaction

Amyloid angiopathy

Vascular malformation (e.g., intracranial aneurysm, venous thrombosis)

Primary/secondary brain tumors

Hemorrhagic conversion of ischemic stroke

Trauma

Drug abuse (e.g., cocaine, amphetamines)

High alcohol intake

Clinical features

Sudden, dramatic, and intense onset

Severe headache

Altered mental status

Photo-/phonophobia

Lethargy

Meningeal signs (prominent with subarachnoid hemorrhage)

Focal neurologic signs

Nausea

Vomiting

Disequilibrium/dizziness (e.g., cerebellar hemorrhage)

Seizures

Exam findings

Abnormal vital signs

Altered level of consciousness

Ocular signs

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  Papilledema

  
  
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  Visual field deficits

  
  
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  Conjugate gaze palsies

Focal neurologic signs

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  Cranial nerve abnormalities

  
  
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  Lateralizing findings

  
  
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  Speech, motor, sensory deficits

  
  
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  Language, cognitive deficits

Meningeal signs

Evidence of craniocerebral trauma (e.g., “raccoon eyes”)

Cardiovascular findings (e.g., carotid bruits, arrhythmias)

Evidence of bleeding diathesis

Management

Call 911/neurology immediately

Prepare for transfer to intensive care unit

ABC management

IV access and slow infusion of normal saline solution

Frequent monitoring of vital signs, cardiac and neurologic status

Control of pain, nausea, vomiting, and seizures

Initial studies may include the following:

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  Head CT

  
  
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  Complete blood cell count with platelet count

  
  
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  PT/INR and aPTT

  
  
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  Chemistry panel

  
  
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  Arterial blood gases if hypoxic

  
  
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  Lateral cervical spine x-ray

  
  
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  EKG

  
  
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  Chest x-ray