What are the key clinical features that differentiate an intracerebral haemorrhage from other types of stroke in a primary care setting?

Key clinical features differentiating intracerebral haemorrhage (ICH) from other types of stroke in a primary care setting include:

• Sudden onset of neurological symptoms: ICH typically presents with sudden neurological deficits similar to ischaemic stroke, but may be accompanied by a more rapid progression of symptoms and decreased level of consciousness.
• Severe headache and vomiting: While headache can occur in ischaemic stroke, a severe headache is more suggestive of haemorrhagic stroke, including ICH.
• Neurological deterioration: Rapid neurological deterioration or decreased Glasgow Coma Scale (GCS) score is more common in ICH due to mass effect and increased intracranial pressure.
• Focal neurological signs: These may be similar in both ischaemic and haemorrhagic stroke, but in ICH they may be accompanied by signs of raised intracranial pressure such as vomiting and reduced consciousness.
• Absence of preceding transient ischaemic attack (TIA) symptoms: TIAs are more commonly associated with ischaemic stroke rather than haemorrhagic stroke.
• Use of validated stroke recognition tools: Tools like FAST can identify stroke symptoms but cannot differentiate ICH from ischaemic stroke; however, clinical suspicion of ICH should be raised if there is rapid deterioration or severe headache.
• Urgent referral and imaging: In primary care, any suspicion of stroke warrants urgent referral; CT brain imaging is essential to differentiate ICH from ischaemic stroke but is not typically performed in primary care.

In summary, while initial clinical features of ICH and ischaemic stroke overlap, key differentiators in primary care include rapid neurological deterioration, decreased consciousness, severe headache, and vomiting, which should prompt urgent hospital referral for imaging and management ¹.