Intracerebral Hemorrhage May Mimic Transient Ischemic Attack

Megan Brooks

January 18, 2016

Patients with intracerebral hemorrhage (ICH) may present with rapidly resolving deficits that mimic transient ischemic attack (TIA), results of a case series suggest.

This series highlights a "previously unrecognized presentation of ICH" and emphasizes its clinical relevance for patient care, particularly brain imaging in patients with transient neurologic symptoms, the authors say.

"Small intracerebral hemorrhages can present with temporary symptoms that are difficult to distinguish from a TIA in the absence of brain imaging," first author Sandeep Kumar, MD, from the Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, told Medscape Medical News.

"The main message is that all patients with such clinical presentation should be imaged promptly and no one should be prescribed antithrombotic agents before eliminating a hemorrhage with a CT [computed tomographic] scan or a brain MRI," he said.

Their report was published online January 4 in JAMA Neurology.

Unusual Presentation

Typically, ICH presents with an abrupt onset of neurologic deficits that often progress over time; nausea, vomiting, impaired consciousness, and significant hypertension are common presenting features.

"Transient symptoms from an ICH are not well recognized and have previously not been reported," Dr Kumar and colleagues note in their article.

They recently saw a patient who developed transient language impairment from a left temporal hemorrhage mimicking a TIA. This prompted them to search the medical records at Beth Israel to determine the frequency of TIA-like presentations of ICH.

Among 2137 patients with spontaneous ICH, 34 had transient deficits that resolved completely within 24 hours of symptom onset. The clinicians say they adopted a 24-hour threshold for labeling a deficit as transient because this cutoff has traditionally been used for defining TIAs.

In their article, they provide details of 17 patients (11 men) with complete medical records. The median patient age was 65 years.

The typical symptoms of ICH, including headache, nausea, vomiting, and reduced alertness, were usually absent. The most common deficits were sensorimotor involving varying degrees of limb weakness, numbness, or incoordination; 3 patients developed significant dysarthria, 2 had major language impairment at onset, and 3 had dizziness with gait unsteadiness.

Most patients had moderate to severe hypertension at presentation, although their neurologic deficits were mild on initial neurologic examination in the emergency department (mean National Institutes of Health Stroke Scale score, 2.3; range, 0 - 5). Five patients took antiplatelet medications of their own accord or on the advice of their doctor before undergoing any imaging studies.

In all patients, the trajectory of clinical improvement began early, usually within several minutes, the clinicians report. In 9 patients, symptoms lasted less than 30 minutes. In 5 patients, they lasted 6 hours or less. Only 1 patient had symptoms linger more than 12 hours but less than 24 hours. None of the 9 patients with detailed follow-up data between 1 and 8 months had a recurrence of symptoms suggestive of a stroke or TIA.

Imaging findings revealed that most of the hemorrhages were subcortical, involving the basal ganglia or neighboring white matter tracts, and small, with an average hematoma volume of 17 mL. No patient had intraventricular hemorrhage or hydrocephalus.

In 8 patients, the cause of ICH was likely hypertensive; 2 patients had probable amyloid angiopathy, 1 had moyamoya disease, and 1 had bleeding from a cavernous angioma. Two cases were likely anticoagulant related, and a definite cause could not be determined in 3 cases.

Implications for Patient Care

Reached for comment, Mark Milstein, MD, neurology residency program director, Montefiore Health System, New York, New York, noted that this presentation of ICH "has not previously been evaluated or described in detail" and it's something clinicians should be aware of.

"This report describes a small group of patients with quickly resolving symptoms presenting with a clinical picture more resembling a transient ischemic attack. The majority of the patients described did not have the typical ICH symptoms of headache, nausea and vomiting that might prompt more emergent evaluation. Awareness of this less common presentation should help guide patient care decisions, including, most importantly, rapid evaluation with neuroimaging and potential changes in medications that might worsen bleeding, such as aspirin or anticoagulation," Dr Milstein told Medscape Medical News.

He cautioned, however, that this is a retrospective study, "so there are some inconsistencies in clinical descriptions and probable referral bias. The authors worked diligently to try to account for this in their evaluation. Finally, this group of patients represented less than 1% of all patients with spontaneous isolated ICH, so it is important to point out that this presentation is very much the clinical exception, rather than the rule."

Also commenting on the report, Robert D. Brown Jr, MD, MPH, Department of Neurology, Mayo Clinic, Rochester, Minnesota, noted that transient neurologic symptoms have a "variety of potential causes including TIA, which is the most common. This article brings to the forefront one of the other potential causes of transient symptoms. And even though this is perhaps the first article that has described this phenomenon, I think in practice many of us have seen this over the years."

"These are small hemorrhages in general," Dr Brown noted, "and many are in the deeper parts of the brain tissue so it's not surprising that a person could develop temporary symptoms related to a small and oftentimes subcortical hemorrhage. Because these hemorrhages were so small, they didn't have some of the other common symptoms that we see in intracerebral hemorrhage."

"When a patient does present with transient neurological symptoms, it does drive home the importance of obtaining a CT scan to be sure there isn't evidence of intracerebral hemorrhage or of subdural hematoma, which can sometimes cause temporary symptoms," Dr Brown added. This will help guide management, he noted.

The study had no funding. The authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online January 4, 2016. Abstract

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