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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Intracerebral haemorrhage (ICH) accounts for ~15% of strokes but ~50% of stroke-related deaths
- CT head shows hyperdense (white) lesion — distinguishes from ischaemic stroke immediately
- DO NOT thrombolyse — thrombolysis is absolutely contraindicated in haemorrhagic stroke
- Reverse anticoagulation urgently if applicable: vitamin K + PCC for warfarin, idarucizumab for dabigatran
- Acute BP target: systolic <140 mmHg using IV labetalol or nicardipine
Overview
Haemorrhagic stroke results from spontaneous bleeding into the brain parenchyma (intracerebral haemorrhage). It accounts for approximately 15% of all strokes but carries a disproportionately high mortality of 40–50% at 30 days. The two most common causes are hypertensive small-vessel disease (typically affecting the basal ganglia, thalamus, pons, and cerebellum) and cerebral amyloid angiopathy (lobar bleeds in elderly patients). Other causes include anticoagulant use, vascular malformations (AVM, cavernoma), coagulopathies, and haemorrhagic transformation of ischaemic infarction.
Epidemiology
Approximately 15,000 cases of ICH occur annually in the UK. Incidence increases sharply with age and is higher in men, Black African/Caribbean populations, and those of South Asian descent. Hypertension is the single most important modifiable risk factor, present in approximately 70% of cases. Other risk factors include anticoagulant therapy (particularly warfarin), excessive alcohol consumption, cocaine or amphetamine use, and cerebral amyloid angiopathy (predominantly affects those over 65 years with recurrent lobar haemorrhages).
Clinical Features
Symptoms
Sudden-onset severe headache — more common than in ischaemic stroke
Rapid-onset focal neurological deficit: hemiparesis, hemisensory loss, dysphasia
Nausea and vomiting — suggests raised intracranial pressure
Reduced consciousness or coma — large haematoma or intraventricular extension
Seizures — occur in ~10% at onset (more common in lobar bleeds)
Progressive neurological deterioration over minutes-hours (unlike embolic stroke which is maximal at onset)
Signs
Contralateral hemiplegia, hemisensory loss, hemianopia (depending on location)
Signs of raised ICP: hypertension, bradycardia, irregular breathing (Cushing response)
Pupil abnormalities: ipsilateral fixed dilated pupil suggests uncal herniation
Cerebellar signs: ataxia, nystagmus, dysarthria (posterior fossa haemorrhage)
GCS reduction — assess and monitor serially
Investigations
First-line
Non-contrast CT headIMMEDIATE — shows hyperdense (white) lesion. Identifies location, size, intraventricular extension, midline shift, and hydrocephalus
BloodsFBC, coagulation screen (PT, APTT, INR), U&Es, LFTs, glucose, group and save
ECGScreen for cardiac arrhythmia — AF predisposes to anticoagulant use
Second-line
CT angiography (CTA)If underlying vascular malformation suspected (young patient, atypical location, no hypertension). Spot sign = active extravasation = poor prognosis
MRI brain (with GRE/SWI sequences)Identifies microbleeds (amyloid angiopathy shows lobar distribution), underlying tumour, or cavernoma. Not urgent
Specialist
Digital subtraction angiography (DSA)Gold standard for AVM/aneurysm if CTA inconclusive and intervention planned
Repeat imagingIf neurological deterioration — haematoma expansion occurs in ~30% within first 24 hours
1
Immediate management
- ABCDE approach; admit to hyperacute stroke unit or neurocritical care
- Urgent reversal of anticoagulation: warfarin = IV vitamin K 5–10 mg + 4-factor PCC; dabigatran = idarucizumab 5 g IV; rivaroxaban/apixaban = andexanet alfa (if available) or PCC
- BP reduction: target systolic <140 mmHg acutely — IV labetalol, nicardipine, or GTN infusion
- Do NOT give antiplatelet agents or anticoagulants
- Seizure management: treat if they occur (IV lorazepam) — routine prophylaxis not recommended
2
Neurosurgical assessment
- Refer urgently if: posterior fossa haemorrhage (risk of brainstem compression and hydrocephalus), hydrocephalus, GCS deterioration, superficial lobar haematoma with mass effect
- Surgical options: haematoma evacuation (craniotomy or minimally invasive), EVD for hydrocephalus, decompressive craniectomy
- Deep basal ganglia haemorrhages are generally NOT amenable to surgery
3
Supportive care and rehabilitation
- Swallowing assessment, DVT prophylaxis (pneumatic compression initially — LMWH deferred until haemostasis confirmed)
- Blood glucose management: target 4–11 mmol/L
- MDT stroke rehabilitation: physiotherapy, occupational therapy, SALT
- Restart anticoagulation for AF after 4–8 weeks if indicated — MDT decision weighing rebleed vs thromboembolic risk
Complications
- Haematoma expansion: Occurs in ~30% within first 24 hours — worsens prognosis. Spot sign on CTA predicts expansion
- Raised ICP and herniation: Large haematomas cause midline shift — may require surgical evacuation or decompressive craniectomy
- Hydrocephalus: Intraventricular extension of blood blocks CSF drainage — may require external ventricular drain (EVD)
- Seizures: Early (within 7 days) in ~10%. Late epilepsy in ~5%
- Venous thromboembolism: DVT/PE from immobility — balance thromboembolic risk against rebleeding
- Aspiration pneumonia: Dysphagia and reduced consciousness — assess swallowing early
UKMLA Exam Tips
- 1CT head: hyperdense (white) = haemorrhage; hypodense (dark) = ischaemia (though ischaemic may be normal early)
- 2DO NOT thrombolyse haemorrhagic stroke — alteplase is absolutely contraindicated
- 3Reverse anticoagulation URGENTLY: warfarin = vitamin K + PCC, dabigatran = idarucizumab, factor Xa inhibitors = andexanet alfa/PCC
- 4Acute BP target: systolic <140 mmHg — reduces haematoma expansion
- 5Posterior fossa haemorrhage = neurosurgical EMERGENCY (risk of brainstem compression and obstructive hydrocephalus)
- 6Cerebral amyloid angiopathy: recurrent lobar bleeds in elderly, microbleeds on MRI GRE/SWI, associated with Alzheimer disease
- 7Haemorrhagic stroke has much higher mortality than ischaemic (~40–50% vs ~15% at 30 days)
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