Clinical and neuroradiological monitoring of patients with haemorrhagic stroke: where, how and when?

Clinical evaluation of patients with stroke, immediately followed by a neuroradiological exam (generally CT scan) is essential for the diagnosis of haemorragic stroke. First-line diagnostic work-up at Emergency Department should be performed as soon as possible after stroke onset in order to limit the consequences of the disease. In particular, cases with clotting abnormalities and/or needing surgical evaluation must be rapidly assessed and treated. Patients without indication to neurosurgery in the emergency setting show a better long-term prognosis (reduced disability/mortality) if admitted to dedicated ward (“Stroke Unit”) rather than general ward. In the acute phase of the disease, blood pressure monitoring appears essential to prevent haematoma growth, which represents a predictor of poor outcome. Nowadays, an on-going international randomized clinical trial (INTERACT 2) is testing if an aggressive reduction of blood pressure (beyond the thresholds suggested by current guidelines) may improve prognosis. Moreover, clinical and instrumental prevention, assessment and treatment of potential complications (such as hyperglicemia, cerebral oedema, seizure, deep venous thrombosis) stand for additional prognostic key-issues. On top of that, further neuroradiological evaluation (with CT, CTA, MRI/MRA and/or endovascular tecniques) in properly selected patients is helpful for the diagnosis and eventually the treatment of the underlying cause of haemorrhage. Finally, advanced neuroimaging, in addition to laboratory exams, could improve the management of patients who has haemorrhagic stroke while taking oral anticoagulants.