In the majority of cases, the hemorrhage has its onset while the patient is up and active; onset during sleep is not common. There is no age predilection among adults except that the average age of occurrence is lower than in thrombotic infarction and neither sex is more disposed. The incidence of hypertensive cerebral hemorrhage is higher in African Americans than in whites and it occurs with higher frequency in people of Japanese descent.
Several general features of intracerebral hemorrhage should be emphasized. Acute reactive hypertension, far exceeding the patient’s chronic hypertensive level, is a feature that, in the context of a stroke, suggests hemorrhage; it is seen particularly with moderate and large clots situated in deep regions. Vomiting at the onset of intracerebral hemorrhage occurs much more frequently than with infarction and likewise suggests bleeding as the cause of an acute hemiparesis. Severe headache is generally considered to be an accompaniment of intracerebral hemorrhage and in many cases it is, but in almost half of cases it has been absent or mild. Nuchal rigidity is infrequent. If there is stiffness of the neck, it characteristically disappears as coma deepens. Or, the patient may be alert and responding accurately when first seen. Only if bleeding into the ventricles is massive or there is substantial distortion of the midbrain, does coma result.
Seizures, usually focal, occur in the first few days in only 10 percent of cases of supratentorial hemorrhage, rarely at the time of the ictus and more commonly as a delayed event, months or years after the hemorrhage. In the selected population of patients with cerebral hemorrhage who are continuously monitored by EEG in an intensive care unit, the frequency may be higher, up to one-third of which half are purely electrographic, according to Claassen and associates. This finding is interesting but does not seem to justify routine EEG monitoring.
The fundi often show hypertensive changes in the arterioles. Infrequently, fresh preretinal (subhyaloid) hemorrhages may occur but they are much more common with ruptured aneurysm, arteriovenous malformation, or severe cranial trauma. Therefore, headache, acute hypertension, and vomiting with hemiplegia in the case of bleeding into the cerebral hemisphere are the cardinal features and serve most dependably to distinguish hemorrhage from ischemic stroke on clinical grounds. In the localization of an intracerebral hemorrhage, ocular signs may be particularly useful. In putaminal hemorrhage, the eyes are deviated to the side opposite the paralysis; in thalamic hemorrhage, the most common ocular abnormality is downward deviation of the eyes and the pupils may be unreactive; in pontine hemorrhage, the eyeballs are fixed and the pupils are tiny but reactive; and in large cerebellar hemorrhage, the eyes may be deviated laterally to the side opposite the lesion and ocular bobbing may occur (as often in cerebellar hemorrhage in awake patients there are no eye signs).
Small hemorrhages in some regions of the brain may escape clinical detection. Usually there are no warnings or prodromal symptoms; headache, dizziness, epistaxis, or other symptoms do not occur with any consistency.