Intracerebral Hemorrhage May Mimic Transient Ischemic Attack

Patients with intracerebral hemorrhage (ICH) may present with rapidly resolving symptoms resembling transient ischemic attacks (TIA), suggesting that immediate evaluation is necessary to rule out ICH, especially before antithrombotic therapy is administered.

After observing a patient with temporal hemorrhage who developed a transient language impairment that mimicked symptoms of TIA, the researchers, led by Sandeep Kumar, MD, of Beth Israel Deaconess Medical Center in Boston, investigated the clinical presentations and prognosis of patients with ICH who experienced transient deficits similar to TIA. Their findings were published in JAMA Neurology

The researchers identified 3207 patients with ICH who had transient deficits that resolved within 24 hours of symptom onset. In all, 17 patients (median age = 65 years; 11 of 17 men) had transient symptoms resembling TIA. Deficits lasted less than 30 minutes in 9 patients, 6 hours or less in 5 patients, and more than 12 hours but less than 24 hours in 1 patient. The most common deficits were sensorimotor, including limb weakness, numbness, and problems with coordination. Three patients developed dysarthia, 2 had major language impairment, and 3 had dizziness with gait unsteadiness. Typical symptoms of ICH, including headache, nausea, and vomiting were usually absent.

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All patients underwent CT scans at admission, which showed subcortical hemorrhages involving the basal ganglia or neighboring white matter tracts, and 2 involving the temporal lobes. All hemorrhages were small (mean (SD) volume of 17 (9.9) mL as measured by the ABC/2 method). Eleven patients underwent brain MRI and magnetic resonance angiography, 5 had CT angiography, and 2 had conventional angiography. In 8 patients, the bleed was deemed hypertensive; 2 had probable amyloid angiopathy; 1 had moyamoya disease; 1 had bleeding from a cavernous angioma; 2 were likely anticoagulant related; and 3 had hemorrhage etiology of unknown origin.

Detailed follow-up information between 1 and 8 months was available for 9 patients, all of whom showed no recurrence of symptoms suggesting stroke or TIA.

“Our report … shows that transient deficits from a minor ICH can mimic a TIA or minor infarct and thus require brain imaging for differentiation,” the authors wrote. “Some of our patients received antiplatelet medications prior to any imaging. While we did not observe any harm in this small group of patients, prescription of these agents can be hazardous in this situation.”

Noting that many of the patients in the study could not be confirmed to have ICH based on typical clinical presentations, the authors emphasized the importance of brain imaging in patients with suspected TIAs, as delays in this process can reduce the sensitivity of detecting hemorrhage.


Kumar S, Selim M, Marchina S, Caplan LR. Transient neurological symptoms in patients with intracerebral hemorrhage. JAMA Neurol. 2015; doi: 10.1001/jamaneurol.2015.4202.